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A TREATISE 

ON THE 

PRACTICE OF MEDICINE. 

BY 
JOHN EBERLE, M.D., 

PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN JEFFERSON MEDICAL COLLEGE; 

OF MATERIA MEDICA AND BOTANY IN THE OHIO MEDICAL COLLEGE; AND 

OF THE THEORY AND PRACTICE OF MEDICINE IN THE TRANSYLVANIA UNIVERSITY; 

MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY; 

OF THE ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA ; AND 

• ORRFSPONDING MEMBER OF THE MEDICO-CHIRURGICAL SOCIETY OF BERLIN, IN PRUSS1 A : 

ETC., ETC., ETC. 

WITH NOTES AND ADDITIONS 

BY 
GEORGE M'CLELLAN, M.D. 

IN TWO VOLUMES. 

VOL. II. 

SIXTH EDITION. 



PHILADELPHIA: 

GRIGG AND ELLIOT, 9 NORTH FOURTH STREET. 

1845. 



* 



.'N 



I 2 + 5 
v. X 
c I 



Entered according to the Act of Congress, in the year 1845 ; by 
JOHN EBERLE, M.D., 

in the Clerk's office of the District Court of the United States in and for the 
Eastern District of Pennsylvania. 



TBILADELPHU: 
T. K. k F. 6. COLLINS, 

pkitjtkt;*;. 



24921 



CONTENTS OF VOLUME II. 



CHRONIC DISEASES. 
CHAPTER I. 

Of Chronic Nervous Diseases. 

Page 

General Observations, 9 

Sect. I. Apoplexy, 12 

Sect. II. Paralysis, ----._.... 31 

1. Hemiplegia, 34 

2. Paraplegia, .......... 3g 

3. Paralysis Partialis, -- 37 

Sect. III. Epilepsy, 49 

Sect IV. Catalepsy, 72 

Sect. V. Chorea, 79 

Sect. VI. Convulsive Affections of Infants, 91 

Sect. VII. Hysteria, 102 

Sect. VIII. Puerperal Convulsions, - - - - * - - 115 

Sect. IX. Tetanus, 120 

Sect. X. Hydrophobia, 135 

CHAPTER II. 

Chronic Nervous Affections, in which Intellectual and Moral Faculties 

are Disordered. 

Sect. I. Mental Derangement, 149 

1. Mania, 159 

2. Monomania, - . 161 

3. Dementia, 163 

4. Idiotism, 164 

Sect. II. Delirium Tremens, 171 

CHAPTER HI. 

Local, Chronic Nervous Affections. 

Sect. I. Neuralgia, 179 

Sect. II. Amaurosis, - 197 



VI CONTENTS. 

Page 
CHAPTER IV. % 

Chronic Affections of the Respiratory Organs. 

Sect. I. Asthma, - 206 

Sect. II. Whooping-Cough, " "^ 

Sect. III. Asphyxia, 231 

Sect. IV. Pneumothorax, " 242 

CHAPTER V. 

Chronic Diseases of the Heart. 

Sect. I. Of the Diseases of the Heart, 247 

1. Hypertrophy of the Heart, 254 

2. Dilatation of the Ventricles, ------ 255 

3. Aneurism of the Aorta, 257 

Sympathetic Affections of the Heart, 263 

Sect. II. Angina Pectoris, 266 

CHAPTER VI. 

Chronic Diseases of the Alimentary Canal. 

Sect. I. Indigestion, 272 

Sect. II. Diarrhoea, 288 

Sect. III. Cholera, 297 

Cholera Infantum, , - 300 

Sect. IV. Colic, 310 

1. Flatulent Colic, 3H 

2. Bilious Colic, 313 

3. Colica Pictonum, 318 

Sect. V. Ileus, 325 

Sect. VI. Constipation, 330 

Sect. VII. Intestinal Worms, • 332 

Sect. VIII. Haemorrhoids, 343 

Sect. IX. Jaundice, 354 

CHAPTER VII. 



Chronic Diseases of the Urinary Organs 
Sect. I. Diabetes Mellitus, --..._ 
Sect II. Diabetes Insipidus, ----._ 
Sect. III. Lithiasis, 

1. Lithic Acid Diathesis, - 

2. Phosphatic Diathesis, - - 

Sect. IV. Ischuria Renalis, 

Sect. V. Retention of Urine, 

Sect. VI. Dysury, 

Sect. VII. Enuresis, 



367 
380 
385 
387 
389 
394 
399 
410 
412 



CONTENTS. Vll 

Page 
CHAPTER VIII. 

Chronic Diseases of the Serous Exhalant Vessels. 

Hydrops, 417 

1. Ascites, 423 

2. Hydrothorax, 424 

3. Anasarca, 425 

CHAPTER IX. 

Chronic Affections of the Lymphatic System. 

Sect I. Scrofula, 442 

Sect II. Bronchocele, - 457 

CHAPTER X. 

Chronic Disorders of the Assimilative Functions. 

Sect. I. Scorbutus, - 468 

Sect. II. Chlorosis, 473 

CHAPTER XL 

Chronic Diseases of the Sexual Organs. 

Sect. I. Gonorrhoea, 479 

Sect. II. Syphilis, 490 

Buboes, - - -- - » -- - - 510 

Sect. III. AmenorrhGea, - - -- 513 

Sect. IV. Dysmenorrhea, 519 

Sect. V. Leucorrhoea, 525 

APPENDIX. 

Cholera Asphyxia — Spasmodic Cholera, 533 



A TREATISE 



PRACTICE OF MEDICINE 



CHRONIC DISEASES. 



CHAPTER I. 



OF CHRONIC NERVOUS DISEASES. 

General Observations. 

The nervous system gives to organized matter all the peculiar 
functions of animal life, and in its higher states of development, ren- 
ders it a fit recipient for the powers of reason and moral feeling, In 
a state of health, or freedom from irritation, it qualifies man for the 
enjoyment and communication of happiness — when disordered, it may 
render him the most deplorable and abject of created beings. Exalted 
mental endowments, equanimity, and benevolence, may be converted 
into imbecility, waywardness, and misanthropy ; meek piety into the 
wildness and intolerance of fanaticism ; confidence into universal 
mistrust, and friendship into hatred, by morbid conditions of this 
component of the human organization. 

The chronic diseases of the nervous system may be divided into 
two classes — viz : 1. Those in which the sensorial or muscular func- 
tions are morbidly affected, either separately or conjointly ; 2. Those 
in which the intellectual and moral powers are disordered. 

The first of these classes comprehends a great variety of affections 
— characterized either by a perversion, or a morbid activity Or abo- 
lition of one or more of the sensorial functions ; or by spasm, or 
convulsion, or paralysis, of a greater or less portion of the muscular 
system. 

The examples of singularly perverted sensorial functions are nu- 
merous. Reil mentions a case in which the whole surface of the body 

VOL. II. — 2 



10 GENERAL OBSERVATIONS. 

was insensible to heat or cold, and incapable by the touch of distin- 
guishing hardness from softness in bodies. Duf'our gives an account 
of a similar case.* Sauvages. relates the case of an individual who 
always heard two voices, one an octave higher than the other, when 
any one spoke to him. Individuals have lost the power of distin- 
guishing colours ; and some have been much harassed by various 
visual illusions. 

Instances of very distressing morbid increase of sensorial power are 
frequently met with. The sense of hearing has become so exceed- 
ingly acute, that the weakest sounds gave rise to pain and uneasiness, 
and the same has been observed with regard to the other sensorial 
powers. In some cases, nervous disorder manifests itself by excru- 
ciating pain in some part of the body, as in the various forms of 
neuralgia. 

The sensorial functions may also be weakened or entirely destroyed, 
by affections seated in the nervous system. When such affections 
are local, one sense alone may be obliterated ; but when the disorder 
implicates the whole of the sensorium commune — the brain — all the 
sensorial powers will be suspended. This general state of nervous 
oppression or inactivity is attended with manifest respiration and 
arterial action, and constitutes what is termed coma; a condition 
which must not be confounded with syncope, or asphyxia. These 
latter affections are not accompanied by any perceptible respiratory 
and arterial actions, and although, like coma, the immediate conse- 
quence of impeded cerebral function, yet they are manifestly depend- 
ent on different conditions of the encephalic circulation. The patho- 
logy in relation to this subject, however, will be illustrated hereafter. 

When the nervous irritation passes upon the muscular system, it 
gives rise to irregular, spasmodic, or convulsive actions, either in one, 
or in several, or in the majority of the muscles of the body. These 
convulsive or spasmodic muscular contractions are divided by au- 
thors into ionic and clonic. In the former, the contractions are per- 
manent, as in tetanus ; in the latter they occur in quick alternation, 
with relaxation, as in hysteria and epilepsy. There exists, however, 
no essential difference between these varieties of convulsive muscular 
action. They indeed often occur at the same time in the same indi- 
vidual, some muscles remaining in a state of firm contraction, whilst 
others are alternately relaxed and contracted. In general, however 
convulsions of the clonic form are attended with less danger than 
those of the rigid or tonic spasmodic affections. The former are fre- 
quently the result of a mere temporary sympathetic irritation of the 
brain, from causes of a transitory character, or susceptible of bein^ 
removed ; whilst the latter usually depend on a more intimate affec- 
tion of the nervous system, from cailses over which we have little or 
no control. Convulsions, or general spasmodic affections of the vol- 
untary muscles, must, therefore, be regarded as the external manifesta- 
tions of certain morbid actions or conditions of the brain and nerves 
The brain, or spinal marrow, is the immediate source of the muscular 

* Reil. Fieberlehre. bd. iv, p. 64. 



GENERAL OBSERVATIONS. 11 

irritation; and the violence, duration, character, and extent of the 
convulsive affection, depend on the nature of the cause, and the 
constitutional habit of the patient. In some instances, the cerebral 
affection which gives rise to the convulsive muscular contractions, is 
so great as to produce a temporary suspension of consciousness, and 
of the sensorial functions. In others, as in tetanus and chorea, the 
mind and sensorial powers remain unaffected until the disease be- 
comes inveterate. 

Spasmodic contractions are often confined to one part, and indeed 
frequently to a single muscle. Of this kind are, tonic spasm of the 
muscles of the eyes, producing strabismus; or convulsive action of 
these muscles, giving rise to rolling of the eyes (hippus) ; spasm of 
the muscles of the lips and face, (sardrosis, risus sardonicus,) giving 
an expression of malignant laughter to the countenance ; tonic con* 
traction of the muscles of the jaws {trismus)-, spasmodic affection 
of the oesophagus ; convulsive action of the diaphragm, producing 
hiccough (singultus) ; tonic spasm of the erector muscles of the penis, 
giving rise to painful, and sometimes protracted priapism ; tonic or 
clonic spasmodic contractions of the abdominal muscles ;* and other 
local spasms or cramps of the voluntary muscles, are among the most 
common affections. 

The involuntary muscles also are subject to spasmodic affections ; 
but these appear to depend more frequently on some local irritation 
than upon a reflected cerebral impression. The whole arterial sys- 
tem is sometimes affected with clonic convulsive action. This is 
particularly apt to occur from sudden and violent mental agitation ; 
from gastric irritation ; and from organic affections of the heart 
(angina pectoris, palpitation). The stomach, the intestinal tube, 
the common gall duct, the urethra, uterus, &c, are all particularly 
liable to painful spasm. 

The second class of nervous diseases, those in which the cerebral 
irritation produces mental derangement, presents a variety of modi- 
fications, both in relation to the degree and the particular character 
of the hallucination. In some instances, there is a general derange- 
ment of all the intellectual faculties, with violent excitement of the 
passions ; occasional exacerbations of raving delirium and agitation 
(mania). In other cases, the insanity is only partial — the patient 
retaining the regular powers of his understanding on all but a few 
or a single subject (monomania). Sometimes the reasoning powers 
become defective or imbecile, and the memory weak or obliterated, 
(dementia,) a state of mind which is most frequently met with in 
very old people, and in such as have suffered frequently from con- 
vulsive affections, as epilepsy, chorea, or apoplexy. In some in- 
stances, almost every trace of intellectual power is wanting, either 
from a congenital defect in the cerebral organization, or from diseases 
or accidental causes affecting the brain. These varieties of mental 

* Whytt mentions the case of a young woman who was affected with constant 
convulsive action of the abdominal muscles during the day, though free from 
them at night when in bed. 



12 APOPLEXY. 

disorder sometimes pass into each other, and present an almost infi- 
nite diversity in their particular phenomena. They may arise from 
causes acting directly on the brain, and from impressions conveyed 
sympathetically to this organ from remote visceral affections. What- 
ever be the nature of the remote cause, however, insanity of every 
variety is always the immediate consequence of some peculiar 
dynamic or organic disorder of the sensorium commune. Under the 
particular head of these affections, I shall enter more fully into the 
etiological consideration of this subject. 

Sect. I. — Apoplexy. 

Apoplexy may be defined, a sudden loss or suspension of the 
animal functions, with a slow and full pulse, laborious breathing, 
generally attended with stertor ; whilst the organic or vital functions 
continue with little or no perceptible disturbance. 

In some instances, the apoplectic attack comes on suddenly with- 
out any precursory indications of its approach. Occasionally, indeed, 
patients feel unusually weil for some time previous to an attack of 
this affection, and this is most apt to be the case in individuals of a 
gouty habit. (Richter.) Much more frequently, however, various 
premonitory symptoms, indicative of cerebral disturbance, precede 
the attack ; and amongst these the following are the most common : 
vertigo ; a dull and deep-seated pain, or sense of weight in the head, 
particularly on stooping, or suddenly turning the head round ; a tur- 
gid state of the veins of the head ; throbbing of the temporal arteries; 
ringing in the ears ; inability to articulate distinctly ; dimness of sight ; 
transient obtuseness of hearing; sparks and flashes of light before the 
eyes; bleeding of the nose; drowsiness; confusion of ideas, mani- 
fested by incoherent talking; disturbed and heavy sleep; loss or 
unusual weakness of the memory ; general sluggishness, both of body 
and mind ; irregular spasmodic contraction of the muscles of the face ; 
and, occasionally, transient pains in the pit of the stomach, and nau- 
sea. In some instances, a numbness is felt in the fingers or in one 
side of the body shortly before the attack supervenes. In general, 
the symptoms which announce the approach of an apoplectic attack, 
indicate an unusual determination of blood to the head. Of these 
symptoms, however, vertigo, ringing in the ears, dimness of sight, 
and pain and heaviness in the head, are by far the most common 
precursors of an attack of this disease. 

The duration of these symptoms is extremely various. In some 
cases, they do not continue more than a few hours before the attack 
ensues ; in others, they occur with occasional remissions or intermis- 
sions, for several weeks or months, and even years. Occasionallv 
the most alarming of the foregoing symptoms occur and continue for 
a longer or shorter time, without terminating in an attack of this dis- 
ease. The premonitory symptoms often become considerablv a°-<?ra- 
vated immediately before the apoplectic attack supervenes. The 
fullness, weight, and pain in the head, become suddenly very severe • 



APOPLEXY. 13 

a sense of tension and drawing is felt in the muscles of the back of 
the neck ; and, in some instances, pain in the epigastrium, with nau- 
sea, occurs just before the attack. 

In some cases the apoplectic attack comes on by a sudden depri- 
vation of all sensorial power and motion ; the patient sinking almost 
instantaneously into a state of profound stupor, resembling deep and 
heavy sleep, from which it is impossible to rouse him in the slightest 
degree. This mode of seizure constitutes what others term perfect 
or strong apoplexy, (apoplexia perfect a, apilepsis, sideratio;) and 
generally terminates fatally in a very few hours, and sometimes in 
less than an hour. 

In other cases, the patient is seized with sudden deep-seated pain 
in the head ; tremor of" the extremities ; confusion of ideas ; nausea or 
vomiting ; and vertigo. He then becomes insensible, and sinks down 
as from syncope ; in a short time, however, he recovers sufficiently to 
converse, and, perhaps, to walk about, but still complains of pain and 
other unpleasant sensations in the head, with confusion of the mind 
and giddiness. In the course of a few hours after this temporary 
recovery, the brain becomes gradually more and more oppressed, 
until complete insensibility is induced, and the patient lies in a state 
of deep coma. 

Sometimes paralysis of one side suddenly occurs, with loss of speech; 
pain in some part of the head ; slowness and confusion of the mind : 
and vertigo ; — the sensorial functions and consciousness remaining. 
By degrees, however, the brain becomes more oppressed, and the 
sensorial powers gradually decline, until profound apoplectic stupor 
ensues.* 

In whatever way the apoplectic attack comes on, the following 
phenomena attend its course, and serve to distinguish it from the other 
forms of soporose affections. Immediately after the accession of the 
fit, the pulse and respiration are weak and often scarcely perceptible. t 
Both, however, soon recover from the first shock ; the pulse becomes 
full, slow, regular, and often hard ; and the respiration slow, oppressed, 

* Abercrombie. Edin. Med. and Surg. Journ., vol. xiv, p. 554. 

t [There is considerable diversity in the character of different cases of apoplexy, 
not only in the mode of attack, but also in the progress of the disease. I have 
seen the face pale, the skin cold, and the pulse very small, weak and tremulous 
for a long period after the attack. In many the face is flushed and tumid, the 
vessels of the temples and scalp prodigiously distended, and the pulse labouring 
from the start. The first class of cases would afford good reason to any observer 
to conclude that something besides, indeed, I might say different from, compression 
is required to produce the symptoms. A difficult or obstructed action of the 
vessels requiring of them a nisus to carry on the circulation through the brain, 
would appear to be the proximate cause of the symptoms of apoplexy. Severe 
pressure may certainly be caused by depressed portions of the skull, or by large 
internal effusions of blood, without producing this condition of the circulation, and 
of course without being followed by apoplexy. On the other hand the same symp- 
toms may have existed before death, and not a source of any kind of compression 
be discoverable in the most careful post-mortem examination. — Ma] 



14 APOPLEXY. 

interrupted or irregular, and generally stertorous. Some writers con- 
tend that in true apoplexy, stertorous breathing is invariably present; 
but this is not confirmed by general experience.* In violent instances, 
expiration is attended with a puffing motion of the lips, and a trotny 
saliva is blown out with a sputtering noise. The face is sometimes 
livid and of a turgid appearance ; more frequently, however, it is pale 
and somewhat bloated. In some instances, the eyes are blood-shot ; 
in others, they are dull, glassy, and fixed, or rolling about in their 
sockets. In general, the pupils are considerably dilated ; and in 
some cases they are permanently contracted. Dr. Cook states that 
he has seen instances in which the pupils were almost entirely closed. 
The extremities are usually below the natural standard of tem- 
perature, but the skin about the body, and particularly of the head, 
is warm. The jaws are generally spasmodically closed; sometimes 
they remain widely open. The power of swallowing is occasionally, 
in very violent cases, entirely destroyed ; but in most instances, though 
greatly impeded, it remains to a degree sufficient to enable the patient 
to swallow small portions of fluids. In all instances, very considera- 
ble torpor of the bowels exists ; and this is sometimes so great as to 
resist every effort to evacuate them by cathartic remedies. Clammy 
sweats usually break out about the head and neck, and the same 
sometimes occur on the extremities. In moderate cases, the tem- 
perature of the skin, and appearance of the countenance, do not differ 
from their natural condition ; and in such cases, the power of deglu- 
tition is generally sufficiently strong to permit the easy administration 
of medicines by the mouth. This is most apt to be the case in what 
is termed upnplexia hydroccphalica, or the apoplectic stage of hydro- 
cephalus. Towards the termination of fatal cases, the pulse becomes 
small, irregular and frequent ; and the respiration slow, short, and 
interrupted by long intervals. 

If the disease does not end in death, it may terminate : — 
1. In the perfect restoration of all the suspended functions, and the 
enjoyment of good health. This favourable issue may be expected 
when the various organs gradually resume their respective functions, 
more especially if consciousness and a command over the voluntary 
muscles gradually return. The tongue is often the first organ that 
obeys the commands of volition ; after this the upper extremities, 
then the inferior ones, resume their power of motion ; the muscles of 
the face being in general the last to return to their regular action. 
Not unfrequently, during the progress of recovery from an attack of 
apoplexy, general and pretty free perspiration, or diarrhoea, and, in 
some instances, active vomiting, occur. Sometimes sanguineous 
evacuations attend the favourable termination of the disease ; such 
as epistaxis or hemorrhoidal and menstrual discharges.! 

* I have seen a case of fatal apoplexy, in which the breathing was throughout 
free from stertor. On post-mortem examination, a coagulum of extravasated blood 
was found in the centre of the right anterior lobe of the brain, and blood was also 
effused into the lateral ventricle of that side. 

t Richiers Specielle Therapie. bd. viii ; p. 711. 



APOPLEXY. 15 

2. In paralysis af certain parts of the body, with a restoration of 
health in all other respects. More or less paralysis, indeed, remains 
after the majority of apopletic attacks. In some instances the palsied 
muscles soon resume their natural power ; in others, they slowly 
recover a certain degree of power, without, however, ever regaining 
their natural state of activity; whilst in some cases little or no per- 
ceptible diminution of the paralytic affection ensues — the affected 
muscles remaining permanently palsied. In most cases in which 
permanent paralysis is left by an attack of apoplexy, the mind be- 
comes very perceptibly weakened. The power of comprehending 
complex ideas and the memory are often almost entirely obliterated 
in persons who recover from a severe apoplectic seizure. Paralysis 
from apoplexy is usually of the hemiplegic variety; but in some 
instances, the palsy is confined to a single member or to certain mus- 
cles, more especially to such as derive their nerves immediately from 
the brain, as those of the face.* 

3. The apoplectic fit may terminate in a general febrile condition 
after the sensorial oppression has passed off. In some instances, strong 
synochal fever is developed in proportion as the nervous functions are 
restored; in others, fever of a typhoid character, with manifest gastric 
irritation, ensues. Several years ago, I was called to a gentleman 
who a few minutes before had been seized with a fit of strong apo- 
plexy. Under the usual treatment he gradually recovered so as to 
be able at the end of the fourth day to sit up and converse without 
difficulty. On the next day strong febrile reaction, with a hot and 
dry skin, supervened, and notwithstanding the most vigorous anti- 
phlogistic measures, violent delirium ensued, and continued for seve- 
ral days before it subsided. The patient eventually recovered. 

Diagnosis. — The diagnosis of apoplexy is not, in general, attended 
with difficulty. Where a loss of consciousness of the sensorial func- 
tions and voluntary motion suddenly comes on, and continues with an 
active state of the pulse and full respiration, the case must be regarded 
as apoplexy. From syncope and asphyxia, this form of soporose 
disease is distinguished by the absence or almost imperceptible action 
of the pulse and respiration in the two former affections. It is some- 
times difficult, however, to distinguish apoplexy from deep intoxica- 
tion. The habits of the individual, the smell of his breath, and the 
general relaxation of all the muscles, particularly those of the jaws and 
the sphincters, will generally lead to a correct diagnosis on this point. 
Dr. Cook observes, that as " the treatment for true apoplexy would not 
be improper for intoxication, a mistake respecting the cause would not 
be hurtful to the patient." This is no doubt correct in reference to 
mistaking intoxication for apoplexy; but if a case of apoplexy were 
mistaken for intoxication, the consequence might be very injurious 
to the patient; for under this mistake the case would probably not be 
subjected to any efficient medical treatment whatever. 

* [The so-called cerebral nerves do not arise from the brain, but are all referable 
to the medulla oblongata. Even the olfactories are traceable to the fibres which 
ascend from the posterior fasciculi of the cord and cerebellum. — Mc ] 



16 APOPLEXY. 

Prognosis.— Apoplexy is always to be regarded as a highly dan- 
gerous affection. When the sensorial functions are completely abo- 
lished, and the respiration is strongly stertorous, intermitting, and 
attended with a sputtering discharge of saliva from the lips, distortion 
of the mouth, immobility of the pupils, and an entire loss of the power 
of swallowing, no reasonable hope can be entertained of a recovery. 
Nevertheless, patients do sometimes, though indeed extremely seldom, 
recover from this affection, after the most profound coma, stertorous 
respiration, and foaming of the mouth have supervened.* In general, 
however, if an appropriate and energetic treatment do not soon make 
a favourable impression upon the disease in its violent form, the case 
may be regarded as hopeless.t 

The duration of the apoplectic attack varies from a few minutes 
to two or three days. In some instances, death almost immediately 
follows the apoplectic seizure. This, indeed, has been doubted by 
some. Dr. Cook thinks that the cases of sudden death which have 
been ascribed to apoplexy, depended, probably, on some affection of 
the heart or large vascular trunks within the chest. There is good 
reason for believing that this has sometimes been the case ; but it is 
by no means improbable, that sudden and exteusive extravasations 
of blood into the substance of the brain, particularly in that part of 
this organ which gives rise to the respiratory nerves, may suddenly 
abolish, not only the sensorial powers and voluntary motion, but also 
the action of respiration, and thus produce speedy death, j Death 
from this affection, however, seldom takes place before the second or 
third hour from the attack. In most instances, indeed, from twenty to 
thirty hours, and in some cases five or six days pass, before the fatal 
termination occurs. 

Besides the unfavourable symptoms mentioned above, there are 
various others which are said to indicate especial danger. When 
the attack commences with sudden severe pain in the head,§ or with 
vomiting,|| or a general spasmodic rigidity of the muscles, the utmost 
degree of danger is to be apprehended. General, clammy and profuse 
perspiration, with a small and frequent pulse, is also a peculiarly un- 
favourable sign. Hippocrates says that the supervention of fever in 
apoplexy is favourable; but Richter observes that this observation can 
only be regarded as generally correct when the fever is of the synochal 
grade, and commences early, for when it supervenes at a late period, 

* Portal, Observations sur la Nature et le Traitement de l'Apoplexie, p. 404. 

t Cook on Nervous Diseases, p. 113. Boston edition. 

% A case is related by Dr. Abercrombie, in which death from apoplexy occurred 
in the space of five minutes. The patient had long complained of headache. 
While sitting in a crowded meeting, apparently in good health, she suddenly fell 
down in a state of insensibility, and expired in a few minutes after. On dissec- 
tion, a thin but extensive layer of extravasated blood was found on the surface of 
the brain; and small coagulawere found also in the substance of the anterior right 
lobe. 

§ Cheyne. 

II Richter, Specielle Therapie ; bd. viii. p. 773. 



APOPLEXY. 



17 



and assumes a typhoid character, it never fails to increase the danger. 
(Loc. cit., 774.) 

The prognosis is also influenced by the character of the exciting 
cause, and still more by the presence or absence of that corporeal 
habit, which experience has shown to predispose especially to this 
affection. 

When there are evident manifestations of some degree of sensi- 
bility remaining, such as contraction of the pupils from the stimulus 
of light; some power of swallowing, &c, together with free and 
regular respiration, without stertor or discharge of saliva from the 
lips ; a warm and general perspiration ; the occurrence of sanguine- 
ous discharges, particularly from the nose or hemorrhoidal vessels ; 
diarrhoea, or a copious flow of urine, reasonable hopes may be enter- 
tained of a favourable issue of the case. 

It was formerly supposed that apoplexy from the rupture of a ves- 
sel, and extravasation of blood into the substance of the brain, is 
always necessarily fatal. This opinion has, however, been satisfac- 
torily controverted by the experience of many of the ablest patho- 
logists of the present day.* The observations and dissections of 
Riobe, Rochoux,t Cruveilhier, Bricheteau, and Serres,^ and we may 
add, of Baillie and Sir Astley Cooper,§ place the occasional recovery 
from strong apoplexy beyond all doubt. From the numerous dis- 
sections made in the Parisian hospitals by the French pathologists 
just mentioned, we learn, that when sanguineous extravasation into 
the substance of the brain does not soon terminate in death, a mem- 
braneous vascular structure is formed around the coagulum, and that 
the coagulum is afterwards absorbed by the vessels of this membrane 
or cyst. In the progress of time, this cyst itself becomes absorbed, 
and leaves a yellowish cicatrix, or laminated, cellular structure, which 
in some instances is found to contain a small portion of reddish serum. 
(Rochoux.)|| 

Sir Astley Cooper thinks, that in apoplexy from sanguineous ex- 
travasation, " the blood never becomes absorbed, but that the brain 
gradually acquires the power of bearing its pressure, and that thus the 
general symptoms which are produced at the first moments of extra- 
vasation gradually diminish."1T That the brain is capable of accom- 

* Recherches sur l'Apoplexie. 

f Considerations et Observations sur l'Apoplexie. 

% Nouvelle Division des Apoplexies. Annuaire Medico-Chirurg., vol. i. 

$ Cook, loc, cit., p. 129. 

II "After the absorption of the extravasated coagulum," says Rochoux, "the 
sides of the cavities approximate, and unite into a kind of cicatrix by the inter- 
vention of a cellular and vascular structure, forming various areola?, between 
which a reddish serous fluid is found. These parietes are much more dense than 
the rest of the brain, about a line or two in thickness, and of a yellowish-brown 
colour. He asserts that these caverns are invariably found after apoplexy termi- 
nating in paralysis, and that their number constantly corresponds with the number 
of previous attacks." 

*[f Cook on Nervous Diseases, p. 129. 
VOL. II. 3 



18 



APOPLEXY. 



modating itself in some degree to unnatural pressure from extravasa- 
tion, or other causes, cannot be doubted. I knew an instance of 
considerable depression of a small portion of the superior and lateral 
part of the os frontis from a fall. The child remained in a state of 
apoplectic insensibility for about twelve hours, and very gradually 
recovered a state of perfect consciousness in about three days. The 
depression still continues, and, with the exception of occasional head- 
ache, no inconvenience appears to remain from the accident. The 
numerous and well-attested facts that have been brought to light by 
the authorities already mentioned, are nevertheless sufficient testimony 
to establish the truth of the occasional absorption of sanguineous 
effusions in the brain. Bricheteau and Riobe have reported numerous 
dissections, " all proving, not only the resorption of the effused fluid, 
but a reunion of the lacerated surfaces afterwards by a kind of cica- 
trization."* 

Causes. — A variety of circumstances, both in relation to the con- 
stitutional habits of individuals, and extraneous influences, appear 
to predispose to this affection. Of these predisposing causes, the 
following are the principal : — 

1. A peculiar conformation of the body; consisting in a large 
head; thick short neck; broad shoulders; ample chest, florid, and 
full face; short stature; globular abdomen, with a tendency to ple- 
thora and obesity. Such individuals are often subject to hemorrhage 
from the nose, as well as to sensations of weight and fullness in the 
head, particularly on stooping, or making strong corporeal exertions. 
When they sleep with the head lying low, they are restless, disturbed 
with dreams, and the respiration is heavy and sonorous. Such a corpo- 
real structure constitutes, no doubt, in many instances, the hereditary 
predisposition to this disease, noticed occasionally in particular fa mi- 
lies, t It is to be presumed also that a peculiar condition of the intimate 
organization may, in some cases, establish a constitutional tendency 
to inordinate determinations to the head, and to the consequent occur- 
rence of apoplexy and other cerebral affections. 

2. Age. — The observation of Hippocrates, that apoplexy occurs 
chiefly between the fortieth and sixtieth years of age, (Aphor. sect. 
vi, Aphor. 27,) still holds good at the present day. Instances of 
apoplexy occur, indeed, at a much earlier period of life, particularly 
between the thirtieth and fortieth years ; but in a general estimate 
it will be found that a very large majority of cases happen after the 
age of forty. Rochoux states, that out of sixty-three cases of this 
disease, two occurred between the ages of twenty and thirty — eight 
between thirty and forty — seven between forty and fifty ten be- 
tween fifty and sixty — twenty between sixty and seventy twenty- 
three between seventy and eighty — and one between eighty and 

* Med. Chir. Rev., June, 1820. 

f Dreysig (Handworterbuch der Med. Klinik., b. i, p. 450), mentions some 
remarkable cases of this kind. Portal and Van Hoven also state that they have 
known families in which a hereditary predisposition to this disease was mani- 
fested. 



APOPLEXY. 19 

ninety years of age. It would appear from this statement, that apo- 
plexies occur more frequently after the age of sixty than at any pre- 
vious period; and this corresponds with the sentiments of Cullen and 
Portal. The greater liability to apoplexy at an advanced period of 
life, cannot be referred to a mere increased tendency to a preternatural 
determination of blood to the head ; for in infancy this tendency is 
acknowledged to be generally greater than at any subsequent period 
of life; and yet apoplexy at this early age is an extremely rare occur- 
rence. Some other circumstances, therefore, connected with ad- 
vanced age, must be the cause of this greater aptitude to the disease. 
Many pathologists have ascribed this increased tendency to apoplexy 
in old people, to an ossified state of the cerebral vessels ; but this 
opinion is not verified by post-mortem examinations. Others, with 
more plausibility, have supposed that it may depend on a weakened 
state of these vessels, similar to that morbid condition of the arterial 
coats which favours the occurrence of aneurism. It is probable, how- 
ever, that this predisposition depends on various circumstances of a 
general character connected with old age, independent of a morbid 
condition of the cerebral vessels. 

3. Whatever tends to produce general plethora, or to keep up 
a preternatural determination of blood to the brain, increases the 
liability to apoplexy. A full and nourishing diet; the habitual use 
of stimulating drinks, particularly in connection with an inactive and 
sedentary course of life, are especially calculated to increase the pre- 
disposition to this disease. Immoderate venereal indulgences at an 
advanced age; frequent, and long-continued warm bathing; a sudden 
change from an active or laborious to a quiet or indolent course of 
life; intense and protracted study; and the free use of strong coffee, 
are mentioned among the predisposing causes of this disease. 

4. Various organic affections, such as aneurism of the aorta; hy- 
pertrophy of the heart; visceral indurations ; and tumours about the 
neck, increase the liability to apoplexy. 

The exciting causes of apoplexy are very numerous. In general, 
whatever produces inordinate determinations of blood to the head, 
or impedes its free return from the brain to the heart, may give rise 
to this disease. 

Over-distension of the stomach by immoderate eating, more espe- 
cially if the ingesta are stimulating and of difficult digestion, and the 
digestive powers weak, is one of the most common and powerful 
exciting causes of apoplexy. The intemperate use of spirituous 
liquors, violent exertions in lifting, much straining in evacuating the 
feces, strong fits of coughing, sneezing, and great exertions in de- 
claiming, playing on wind instruments, singing, laughing, or speak- 
ing, by causing sudden and strong determinations of blood to the 
head, may produce this disease in individuals predisposed to it. Ex- 
posure to the direct rays of the sun in warm climates, gives rise to 
that sudden and fatal affection called stroke of the sun, and which 
is generally regarded as apoplexy. Extreme cold also is capable of 
producing this affection, by diminishing the circulation in the exter- 
nal vessels, and causing strong internal congestions. Violent and 



20 APOPLEXY. 

sudden mental excitement, rage, excessive joy, terror, and deep sor- 
row, have been known to produce this disease. The suppression ot 
habitual discharges, whether sanguineous or serous, may give rise 
to apoplexy. This is particularly the case with habitual hemor- 
rhoidal discharge or epistaxis in plethoric subjects. The healing up 
of old ulcers has a tendency also to produce this disease in persons 
otherwise predisposed to it, (Schmucker's Vermisch. Schriften.h. 
iii, p. 149 ;) and the neglect of customary venesection in full habits 
may tend to the same effect.* Stoll mentions the sudden disappear- 
ance of oedema of the feet as an exciting cause of apoplexy (Ratio. 
Medend. Pars, iii, p. 305). Women in the puerperal state "are in 
some degree liable to apoplexy." Dr. Davis, of London, states that 
he has met with four or five apoplectic seizures and consequent 
hemiplegia, in puerperal women. In all these cases, the habitus 
apoplecticus mentioned above was present.t Tumours or visceral 
indurations in the abdomen, by pressing on the aorta, may give rise 
to this disease. Morgagni relates an instance which was produced 
apparently by an enlarged spleen pressing on the aorta. 

Apoplexy may also occur in consequence of the repulsion of chronic 
cutaneous diseases; and it is frequently the result of metastasis of gout. 
Authors mention also translations of rheumatism, erysipelas, and of 
other exanthematous affections, among the exciting causes of this 
disease. I knew an instance in which it appeared to be brought on by 
a very severe attack of mumps. Violent rigors or chills, particularly 
the severe and protracted chills of intermittents, sometimes give rise to 
apoplexy. I have known several fatal instances of this kind. In one 
case, I stood by the patient when he was seized with the chills ; in 
about ten minutes after they commenced he became insensible ; fell 
into convulsions, and quickly passed into a profound apoplectic stupor, 
from which he did not recover. The patient was an old, corpulent, 
and very plethoric man. Intestinal irritation may also cause so 
strong a determination of blood to the brain as to give rise to this 
affection.^ 

Besides the foregoing causes, which operate apparently by causing 
undue determinations to the vessels of the brain, apoplexy may also 
be produced by causes that impede the free return of the venous 
blood from the head to the heart. Stooping, or other situations in 
which the head remains in a depending position ; wearing tight 
cravats, and turning the head round to look back, by which the 
jugular veins are in some degree compressed ; impeded circulation 
through the lungs; organic diseases of the hearty tumours on the 

* Vogel. Prselectiones Academ., $ 558. 

f Dr. Davis. Medico-Chirarg. Rev., April, 1825. 

$ There is, indeed, much reason to believe that gastro-intestinal irritation is a 
very common exciting cause of apoplexy. Thilenius ; (Medicin.-Chirurg. Be- 
merku-ngen., p. 66.) Also Schroder, (De Apoplexue ex prcecordior. vitiis Origine 
Analecta in Opusc, vol. ii, p. 388,)— as quoted in Jahn's Klinik der Chronischen 
Krankheiten, bd. i, p. 340. 

$ See Medico-Chirurg. Rev., January, 1820, pp. 343 and 345. 



APOPLEXY. 21 

neck, or in situations where they may press upon the veins which 
convey the blood from the head, are the principal of these causes. 

Authors mention also excessive evacuations among the occasional 
causes of this disease. Boerhaave states, that he knew an instance 
of apoplexy apparently produced by an excessive hemorrhage from 
the nose. The tendency of excessive sanguineous evacuations to 
produce soporose or cerebral oppression very similar to apoplexy, 
has already been adverted to under the general head of hemorrhages. 
The work of Marshall Hall, referred to in that place, gives some 
very interesting observations on this subject. It is certainly a very 
remarkable circumstance, and not accordant with the present received 
pathology of apoplexy, that entire insensibility, with stertorous breath- 
ing, sometimes results from profuse hemorrhage.* Diabetes some- 
times terminates fatally, under symptoms strongly resembling apo- 
plexy ; and the same termination has been noticed in excessive 
diarrhoea and cholera. (Richter.) Peculiar atmospheric constitutions 
have also been ranked among the exciting causes of apoplexy ; and 
from causes of this kind, this disease has at times prevailed epi- 
demically.! Besides the authorities referred to below, we have also 
the more recent testimony of Weikard, ( Vermisch. Schriften., st. i, 
p. 292, st. ii, p. 65,) and of Jahn, (Klinik d. Chronisch. Krankho.it., 
b. i, p. 333,) in confirmation of this fact ; and Baglivi mentions the 
epidemic occurrence of this affection. Richter states, that a humid, 
cold, and variable state of the atmosphere appears to be most 
favourable to the occurrence of apoplexy. It is improbable, however, 
that a condition of the atmosphere depends more upon its electrical 
and barometrical state, than on its relative degrees of humidity and 
temperature. This atmospheric tendency to produce or favour the 
production of apoplexy is sometimes limited to a few days of con- 
tinuance. Thus Thilenuis states, that in the course of a few days, 
nine persons were seized with apoplexy in one district. (Bemerk., 
b. i, p. 67.— Richter.)X 

Various organic affections of the brain and its meninges, and the 
narcotic poisons, are also enumerated among the exciting causes of 
this disease. Gregory doubts whether these latter can, with pro- 
priety, be considered as exciting causes of apoplexy. As they tend, 
however, to cause strong congestion in the vessels of the brain, they 
may, no doubt, excite this affection in persons otherwise predisposed 
to it, as other causes do that strongly determine the circulation to the 
head. 

Pathology. — What is the immediate cause of the abolition of 
sensorial power and voluntary motion in apoplexy? Pathologists 

* For an interesting example of this kind, see Mr. Browus case of uterine 
hemorrhage, reported in the London Medical and Physical Journal — 1827. 

t Agathias. De Bello Gothico, in Hugo Grotii. Histor. Gothorum., p. 568. See 
also, Lepecq. de Clotiere. Anleit. f. Aerzte, Epidem. Krankh. Zubeobacht., p. 412. 
Fr. Hoffman. Medic. Ration. System., torn. ii ; p. 11, s. 11, p. 529 — as quoted by 
Richter, Specielle Therapie, vol. viii, p. 755. 

% Vide Macullough on Malaria. 



22 APOPLEXY. 

are far from being unanimous in their answers to this question. Some 
maintain that pressure on the cerebral mass is always the immediate 
cause of the characteristic phenomena of this disease ; others suppose 
that they depend not on pressure, but simply upon interrupted cir- 
culation in the brain ;* whilst some believe that the encephalic ettu- 
sions are the consequence of a previous morbid change in the brain, 
(Rochoux,) upon which the loss of sense and motion depends. Some 
pathologists confine the term apoplexy strictly to sanguineous extra- 
vasation within the brain; others include serous effusions among the 
immediate causes of the disease; and many believe, and correctly, 
too, that mere vascular turgescence, without effusions of any kind, 
frequently produces apoplexy. 

From a careful examination of much of what has been written 
on this subject, as well as from my own observations, it appears to 
me clear that the opinion which assigns the characteristic phenomena 
of apoplexy to pressure of the brain, is the correct doctrine on this 
point. 

Post-mortem examination detects in those who die of apoplexy 
one or more of the following phenomena : — 1, vascular turgescence 
of the brain; 2, sanguineous extravasation into the substance of the 
brain ; 3, serum effused into the ventricles or upon the surface of the 
brain ; and 4, no cognizable cerebral disorder whatever. Of these 
four conditions, the first only ought, I think, to be considered as pri- 
mary or essential ; the others being consecutive, and not immediately 
concerned as a cause in the apoplectic seizure. 

When blood flows more rapidly into the arteries of the brain than 
it can be returned by the veins, preternatural distension of the cere- 
bral vessels must be the consequence ; and this general vascular 
turgescence must exert an unusual degree of pressure on the cere- 
bral mass. 

That such vascular engorgement and consequent pressure on the 
brain are capable of producing all the peculiar symptoms of apoplexy, 
admits of no doubt. In some instances of fatal apoplexy, the vessels 
of the brain are found so much engorged with blood, as to render 
even the smallest branches very conspicuous, and to give a more 
or less deep red tint to certain portions of the cerebral mass without 
any sanguineous or serous effusions.t Richter says that an extremely 
congested state of the cerebral vessels is sometimes the only morbid 
condition visible within the head.f Bricheteau also observes, "that 
we often find a general turgescence of the cerebral vessels, which 
congestion causes a general pressure on the encephalic mass, sufficient 
to extinguish the nervous influence, and destroy life."§ Morgagni 
has related a case in which he found, on dissection, the whole vascular 
system of the brain extremely engorged with fluid blood. Dr. James 
Johnson, in commenting on this case, observes — " that apoplexy is 

* Abercrombie. Researches on the Pathology of the Brain in Apoplexy. 

t Portal. Resultats de l'Ouverture des Corps. 

% Specielle Therapie, bd. viii, p. 718. 

$ Journal Complementaire du Diet, des Scien. Med., p. 296. 



APOPLEXY. 23 

frequently produced by turgescence of the vessels alone, was believed 
in ancient times as well as in modern. It is, indeed, reasonable to 
suppose, that in the majority of apoplectic recoveries, congestion 
only had taken place in the vessels of the brain. But if congestion 
gives rise to the most favourable cases, it appears capable of pro- 
ducing the most desperate and instantaneously fatal ones also."* Dr. 
Fouquier, also, has reported a case of fatal apoplexy, which was 
manifestly the result of mere sanguineous engorgement of the brain. 
" The exterior vessels of the brain, and those of the choroid plexus 
were much engorged with blood;" and the interior of the cerebral 
mass, when sliced off, presented a multitude of red points. Neither 
serous nor sanguineous effusion was present. t 

Strong and sudden sanguineous engorgement of the cerebral vessels 
is, probably, always one of the first morbid conditions in the occur- 
rence of apoplexy — the immediate result of diminished vital resist- 
ance in the vessels of the brain, and a preternatural afflux of blood 
to these vessels. (Johnson.) This vascular turgescence may pass off 
again under proper remedial measures; or it may terminate speedily 
in sanguineous extravasation into the brain ; or continue, finally, 
without any effusions, until it terminates the patient's life. What is 
usually termed serous apoplexy is perhaps only one of the termina- 
tions of apoplexy from vascular turgescence. A sudden violent 
determination of blood to the brain, and consequent cerebral com- 
pression, may immediately destroy all sense and voluntary motion. 
If the vessels be not relieved by extravasation or by immediate 
applications, they may, in the course of some hours, relieve them- 
selves by serous effusion, as they do in hydrocephalus acutus ; and 
this effusion must then become a secondary but permanent cause of 
cerebral compression. It is unnecessary here to adduce any argu- 
ments in support of this pathology of serous apoplexy. We often 
meet with striking examples of sudden serous or lymphatic effusions 
from vascular engorgement. Every one has heard of the affection 
usually called apoplexy of the lungs. Sudden and often fatal effu- 
sions of this kind occur into the substance of the lungs from violent 
engorgement of its blood-vessels. 

It appears highly probable, therefore, that strong vascular turges- 
cence of the encephalic mass constitutes the primary pathological 
condition of apoplexy. This state often terminates almost imme- 
diately in sanguineous extravasation, or at a later period in serous 
effusion ; and both these consequences constitute, of course, addi- 
tional causes of cerebral compression.^ 

* Medico-Chir. Rev., June, 1820, p. 9. 

t Annuaire Medico-Chirurgicale, vol. i, p. 376. 

% M. Serres contends that both sanguineous and serous affections are always the 
effect, and not the cause of apoplexy. He denies that pressure, in any case, is 
capable of producing either this disease or hemiplegia. He thinks, that what is 
usually termed serous apoplexy depends on disease of the meninges; apoplexy 
with paralysis, he says, is the immediate consequence of an altered state of the 
cerebral structure, attended generally with sanguineous extravasation as a secondary 



24 APOPLEXY. 

To this view of the pathology of apoplexy, it has been objected, 
that cases sometimes occur in which the brain on dissection exhibits 
no traces whatever of vascular congestion, nor any other obvious 
lesions. Petzold has related instances of this kind, which he ascribes 
to inanition of the cerebral vessels, and in which not the slightest 
unnatural appearances were discovered on dissection, except an 
empty and collapsed state of the vessels of the brain.* Such cases 
are, however, extremely uncommon ; and do not, upon proper 
inquiry, militate against the doctrine advocated above. Upon this 
point Dr. Johnson observes, " that there is nothing more certain than 
that the vascular turgescence in the brain may so far subside, in the 
interval between death and dissection, as to leave no trace of its pre- 
vious existence. This, in fact," he continues, " we consider to be the 
natural and true solution of the difficulty respecting the cause of apo- 
plexy in those cases where the scalpel cannot detect deviations from 
the healthy structure. "t There is, however, another objection that 
has been urged against the doctrine of cerebral compression as the 
exclusive cause of apoplexy, which, though plausible, possesses no 
real weight. It is stated, and correctly, that all the external manifesta- 
tions of strong apoplexy are sometimes the immediate result of ex- 
cessive hemorrhage. I have already referred to the case reported by 
Mr. Brown, in which entire insensibility and stertorous breathing 
were the immediate consequences of excessive uterine hemorrhage, 
and which were removed by transfusing blood from another person 
into the patient's veins.f Dr. Denman has also related an instance of 

result. His reasons for denying the agency of pressure in the causation of this 
affection, are derived from the fact, that fatal apoplexy sometimes occurs without 
any effusion or extravasation, or even vascular turgescence appearing on dissec- 
tion ; (a) and from some experiments which he made on animals, in which the 
cranium was opened, and a vessel wounded, and the blood carefully confined 
within the head by closing up the external opening. Although much blood was 
thus extravasated and lodged into the great interlobular scissure and upon the 
surface of the brain, no comatose or paralytic affections ensued. These views, 
so far as cerebral pressure is concerned in the production of the disease, are, 
however, directly contradicted by the results of some experiments made in rela- 
tion to this subject by Portal. This pathologist trepanned the cranium of a dog. 
By different degrees of pressure made on the brain through the opening with the 
finger or a piece of wood, he could at pleasure produce convulsions, or coma, 
and apoplectic stertor: and Sir Astley Cooper obtained the same results from simi- 
lar experiments made on a dog. (b) . 

* Dissert, de apoplexia ex inanitione vasorum cerebri Goett. 1785 

t Med. Chir. Rev., Jane, 1820, p. 8. 

X Loud. Med. and Physical Journal, 1827. 

(a) [I have made three post-mortem examinations after apoplexy in which there 
was no extravasation or effusion, but general sanguine engorgement Drevail^ in 
all of them.— Mc] V 

(b) Cook on Nervous Diseases. 



APOPLEXY. 25 

apoplectic symptoms supervening on very profuse hemorrhage,* and 
many more cases of this kind might be collected. In relation to such 
cases it is to be observed, that great losses of blood are peculiarly 
favourable to extraordinary determinations to the brain, or, as 
Marshall Hall expresses it, "to increased action and fullness of the 
cerebral vessels."! The experiments of Kellie, on animals, show 
that serous effusion within the head is a pretty constant concomitant 
or consequence of excessive sanguineous depletion ; and the experi- 
ments of Dr. Seeds go to establish the same fact.J 

The sanguineous extravasations are usually found in the corpus 
striatum, or in the thalami nervorum opticorum. Out of forty-one 
dissections, Rochoux met with but five or six instances of extrava- 
sation in other parts of the brain : and the observations of Morgagni 
give nearly the same result. § Extravasation of blood into the cere- 
bellum is an extremely rare occurrence. According to Rochoux it 
hardly happens once in fifty cases; and Morgagni reports only one 
instance of this kind. "Blood is rarely effused, in the first instance, 
into the ventricles. During ten years' observation in the different 
hospitals, M. Bricheteau saw only two cases of this kind. The fluid 
is generally extravasated in the neighbourhood of the ventricles, and 
bursts into them by a ragged opening." [Med. Chir. Rev., loc. cit.) 
Occasionally blood has been found effused on the surface of the 
brain. Rochoux relates a case of this kind; and Richter states that 
sometimes the brain, on removing the cranium, appears dark, brown, 
or blackish, through the membranes, from extravasated blood under- 
neath. {Loc. cit., b. viii, p. 719.) The old division of apoplexy into 
sanguineous and serous, possesses no importance in a practical point 
of view. I have already stated that the effused serum sometimes 
found within the head on dissection, is very probably not the imme- 
diate cause of the apoplectic seizure, but one of the results of the vas- 
cular engorgement, upon which the apoplexy depends. There are, 
nevertheless, some circumstances connected with this distinction, 
which it may be proper to notice. Thus, it appears, from the obser- 
vations of M. Serres, that when the apoplectic attack is complicated 
with hemiplegia, we may infer that there is extravasation of blood 

* Trans, of a Soc. for the Improv. of Med. and Surg. Knowledge, vol. iii, p. 
315. 

t Medical Essays, p. 68. 

$ M. Seeds, in six experiments performed on animals which he bled to death, 
found the contents of the cranium and spinal canal so engorged with blood, that 
it might at first sight have been thought that blood-letting would have saved the 
animals. — Medico- Chir urg. Journ. and Review, vol. i. 

$ In explanation of this fact, M. Bricheteau observes, " An attentive study of 
the vascular system of the brain shows us that a number of arteries penetrate 
directly into these parts — the corpus striatum, &c. ; without dividing themselves 
in the pi a mater, as the other vessels do which serve to nourish the brain. In 
consequence of this they are without any additional membranous support in the 
middle of the cerebral mass, the consistence of which is but illy calculated to sup- 
port them against the impulse of the blood." — Loc. cit. 



26 APOPLEXY. 

into the cerebral substance. When, on the other hand, the disease 
is accompanied with paralysis, we may presume that the substance 
of the brain remains uninjured, and that more or less serum, or sero- 
sanguineous fluid, is effused by the congested and irritated meninges 
upon the surface, or into the natural cavities of the brain. 1 he tor- 
mer variety— that is, the complicated or paralytic form of the disease 
— M. Serres calls cerebral apoplexy, from the cerebral mass itself 
being the principal seat of the morbid changes. The latter, or un- 
complicated variety, he denominates meningeal apoplexy, on account 
of the manifest traces of vascular irritation and congestion, discovered 
by dissection, in the meninges. It appears from the observations 
made in the Parisian hospitals, that meningeal or serous apoplexy 
occurs chiefly before the fifteenth and after the sixtieth year of age ; 
and that females are more liable to this variety of the disease than 
males. 

When blood is extravasated into one hemisphere of the brain, the 
consequent paralysis occurs almost universally on the opposite side of 
the body. The paralysis is occasionally general — both sides of the 
body being equally affected. In such cases the mouth is not drawn to 
either side, and the patient dies as from asphyxia : or as animals do 
which have the pneumogastric nerves of both sides divided. The ex- 
travasation, in cases of this violent character, takes place into the sub- 
stance of the tuber annulare, or bursts from thence and spreads along 
the basis of the skull. (Serres ) The existence of hemiplegia may, in 
general, be readily detected by the distortion of the mouth ; for, how- 
ever profound the apoplectic stupor may be, more or less deviation 
from the natural position of the mouth is almost, universally present. 

Treatment. — The main object to be kept in view in the treatment 
of apoplexy, is the removal of the vascular turgescence within the 
head. This fundamental indication is to be answered by a prompt 
reduction of the general mass and momentum of the blood; and by 
the employment of means calculated to lessen the determination of 
the blood to the brain, and to derive it from the cerebral vessels. 

In the actual paroxysm of apoplexy, the patient should be imme- 
diately removed to an airy and cool situation, and placed in a position 
which least favours the flow of blood to the head. All ligatures, par- 
ticularly those about the neck, should be speedily removed, and his 
head and shoulders supported in an elevated position. In this posture, 
a large orifice should be made into a vein, and the blood suffered to 
flow until a very decided impression is made on the pulse, at the same 
time that cloths, wet with cold water, are applied to the shaven scalp, 
and warm or stimulating applications— such as fomentations, sina- 
pisms, or frictions with tincture of capsicum— made to the legs and 
feet. Cups may also be very beneficially applied to the temples and 
back of the neck, conjointly with the means just mentioned. Some 
advise bleeding from the temporal artery or the jugular vein in prefer- 
ence to brachial venesection ; but others do not regard this preference 
as founded on good grounds. It is nevertheless very probable that 
blood promptly drawn from the jugular veins or temporal arteries will 
have a more direct and speedy effect in diminishing the sanguineous 



APOPLEXY. 27 

congestion in the brain, than if it be taken from the arm ; and as the 
accomplishment of this effect constitutes our chief purpose in the em- 
ployment of blood-letting, we may with propriety adopt this mode of 
depletion. In whatever way the blood is drawn, little or no advantage 
will be obtained, unless a sufficient quantity is abstracted to produce 
a very obvious impression on the action of the pulse ; and this effect 
can seldom be produced without the loss of from thirty to forty ounces 
of blood at once. If in the course of an hour the pulse resumes its 
activity, a second venesection should be practised, and repeated after- 
wards at longer or shorter intervals, as long as the pulse indicates the 
propriety of further depletion. It is sometimes necessary to abstract 
a vast quantity of blood before the disease begins to subside. " From 
six to eight pounds of blood have been taken from a person by no 
means robust, before the disease began to yield."* I have myself 
drawn five pounds of blood from an apoplectic patient in the course 
of six hours after the seizure with entire success. In the employ- 
ment of blood-letting we may suffer ourselves to be guided by the 
pulse, as has just been stated. Nevertheless, the judicious practi- 
tioner will regulate the extent to which this evacuation is carried, 
not only by its effects on the pulse, but by an attention also to the 
age and constitutional habit of the patient. I have met with a case 
of apoplexy which ultimately proved fatal, in which the loss of thirty 
ounces of blood produced, almost immediately, much feebleness of 
the pulse. The patient was a female, beyond the seventieth year of 
age. 

Leeching is of no service beyond what may result from the general 
diminution of the circulation. Cupping, however, is a most, import- 
ant auxiliary.! After an efficient venesection, the application of cups 
along the temples and back of the neck, or to the shaven scalp, will 
sometimes speedily rouse the patient from his stupor.J 

The application of ice, or very cold water to the scalp, is one of the 
most useful remedies in this disease. This was a favourite measure 
with Thilenius,§ and his praise of its powers, though great, can 
scarcely be deemed extravagant. Its efficacy will be much en- 
hanced by the simultaneous application of warmth, or stimulating 

* Cheyne. 

1 1 very much admire the mode of cupping recommended by Mr. Wallace, (a) 
It is as follows : A cupping-glass having been exhausted in the usual way, is ap- 
plied to the surface until the skin is sufficiently raised. A very sharp gum lancet 
is then to be lightly and rapidly drawn over the skin, so as to make superficial in- 
cisions about the sixth of an inch from each other, over the whole surface raised by 
the exhausted cup. These incisions should be so slight as to be scarcely visible. 
The moment the cupping-glasses are reapplied, the blood will be found to stream 
from them with surprising rapidity. 

$ Dreysig, loc.cit., p. 481. 

$ Medicinische und Chirurgische Bemerkungen, p. 62, et seq. 



(a) A Physiological Inquiry into the Action of Moxa, &c. By Mr. William 
Wallace, M. R. I. A. ; Surgeon of the Charitable Infirmary of Dublin, &c. &c, p. 62. 



28 



APOPLEXY. 



frictions to the legs and feet. Of course, where the pulse is feeble, and 
the countenance pale, cold must be cautiously applied, but stimulating 
and warming applications to the lower extremities are always proper. 
Formerly, blood-letting was regarded as of very doubtful propriety 
in this affection; but at the present day its usefulness, or rather its 
indispensableness, in every case of genuine apoplexy, is universally 
acknowledged. 

•Active purgatives also are among our most efficient remedies in 
this affection. As the advantages derived from them depend, no 
doubt, in most instances, chiefly on the tendency they have to direct 
the circulation more particularly to the intestines, and to excite a free 
secretion from their internal surface, and consequently to diminish the 
afflux of blood to the head, it is evident that the more rapidly they 
operate, the more beneficial will be their influence. On this account, 
as well as from the great intestinal torpor which prevails in this affec- 
tion, it is necessary to employ the most active articles of this class of 
medicines. It is, however, often extremely difficult, and in violent 
instances, sometimes impossible to administer cathartics by the mouth, 
from the paralyzed state of the organs of deglutition. Where the 
power of swallowing is wholly destroyed, we may introduce a purga- 
tive fluid into the stomach through an elastic stomach tube. Calomel 
and extract of jalap are recommended by Sir Gilbert Blane as the best 
purgative in this affection. Calomel and colocynth form also a suita- 
ble purgative. I have used the oil of croton, rubbed up with a little 
gum Arabic and water, with excellent effect in two instances of apo- 
plexy. This article generally acts with much energy, and from its 
small bulk and fluidity, is more easily introduced into the stomach 
than other remedies of this kind. Castor oil with turpentine, also 
forms an excellent purgative in this disease. At the same time that 
cathartics are given by the mouth, active purgative enemata should be 
repeatedly administered. For this purpose we may use a solution of 
aloes in warm water, in the proportion of from thirty to forty grains 
to the pint of water ; or a strong infusion of senna. Richter advises a 
solution of tartar emetic for this purpose. Where the vascular reac- 
tion is vigorous, this solution may be peculiarly serviceable, by the 
nausea and consequent reduction of arterial excitement which it is apt 
to produce, as well as by its evacuant effects on the bowels. 

Purgatives are particularly useful where the bowels are in a loaded 
condition. Dr. Abercrombie relates some instances of this disease, 
in which blood-letting afforded but very little advantage. As soon, 
however, as the bowels were freely evacuated, a very obvious im- 
provement took place. Where the inordinate flow of blood to the 
brain is caused or supported by intestinal irritation from accumulation 
of feculent matter, or the presence of vitiated secretions, it would seem 
in vain to expect decided benefit from bleeding or any other remedy, 
unless the bowels are freely moved ; and it is in such cases especially 
that cathartics are of primary importance. 

Formerly emetics were much extolled for their remedial powers 
in apoplexy. Van Helmont, Riverius, StolL, and Burserius, placed 



apoplexy. 29 

much dependence on them in the treatment of this disease.* Since 
the time of Cullen, however, they have been generally abandoned, 
as much more calculated to do mischief than good.t Unquestionably, 
as a general rule, emetics must be regarded as hazardous remedies 
in apoplexy ; for the tendency of vomiting to propel the blood to the 
head is always very considerable. Nevertheless, this disease may 
occur under circumstances of gastric irritation, which may not only 
render emesis useful, but absolutely indispensable to success. When 
the apoplectic seizure occurs soon after taking a very full meal of 
stimulating food, an emetic ought undoubtedly to be given. But even 
under the most urgent indications for the exhibition of an emetic, a 
copious and efficient abstraction of blood should always be premised. 
A few years ago, I met with a striking instance of the usefulness of 
emetics in apoplexy, under the circumstances just mentioned. A 
robust man, about fifty years of age, fell down in a fit of apoplexy 
about an hour after he had taken a very full meal of animal food, 
with several glasses of brandy and water. The coma was profound, 
and the respiration stertorous and sputtering. He was immediately bled 
to the extent of about forty-eight ounces, but although the pulse was 
considerably reduced, no perceptible improvement ensued. Twenty 
grains of sulphate of zinc were with difficulty introduced into his sto- 
mach, and free vomiting ensued in about ten minutes after. Almost 
immediately after the contents of the stomach were thrown off, he 
became better; and by- the use of purgatives, enemata, and cups to 
the head, he recovered without any further difficulty.^ Dr. Gregory 
says, " in certain cases vomits are proper ; but they should never be 
given till after large evacuations by blood-letting. They are the 
most proper where the^ disease proceeds from a surfeit; and in serovs 
habits vomits are very efficacious. "§ Authors generally advise the 
mildest emetics in cases where they are indicated. Heberden gave 
a weak infusion of chamomile : Cheyne used lukewarm water with 
hartshorn ; and others recommend warm water with mustard. It 
is very questionable, however, whether any peculiar advantages 
attend the use of these milder emetics. Indeed, the system is almost 
always so insensible to the impressions of medicines that nothing but 
the most active articles in large doses, will procure emesis. Where 

* Burserius. Inst. Med. Pract., vol. iii, § 131, p. 106. 

f See Lond. Med. and Phys. Journ., vol. v and vi, for an ample discussion on 
this subject. 

X [I have repeatedly met with such cases. Indeed, in the majority of violent 
apoplexies, I have observed that undigested crudities have caused the disease. 
A robust and corpulent gentleman of this city has experienced three violent 
seizures under my care, from all of which he has been promptly relieved by 
active emetics following previous venesection. No paralysis occurred after these 
attacks. A patient of the late Dr. Klapp had been several days totally insen- 
sible and prostrate from a severe attack, when he was suddenly and completely 
relieved by the discharge of a soused pig's ear, under the action of an emetic. — 
Mb.] 

$ MS. Lecture as quoted in the Med- Chirurg. Rev., June, 1820, p. 26 



30 APOPLEXY. 

there are indications present to justify the exhibition of an emetic, 
the more promptly the stomach is evacuated the better. Richter, 
who speaks very favourably of the employment of emetics in cases ot 
this kind, advises the most active articles of this class.* 

Blisters do not appear to alford any advantage in apoplexy, unless 
the pulse is weak, small, and quick, which, though rarely, is some- 
times the case, in old and enfeebled persons of leucophlegmatic 
habits. At all times, however, it is better to apply them to the 
ankles and wrists than to the head or back of the neck. 

It is scarcely necessary to say, that stimulants are decidedly impro- 
per in the early period of apoplexy. Where, after copious evacua- 
tions, some degree of consciousness and a power of voluntary motion 
return, with much prostration and a feeble pulse, some benefit may 
perhaps be obtained from the cautious exhibition of the carbonate of 
ammonia or camphor, (Richter,) in the form of a mucilaginous mix- 
ture. 

The prompt and judicious employment of the foregoing means, 
embraces every thing that may be deemed efficient in the remedial 
management of apoplexy. From whatever cause the disease may 
arise, our whole efforts should be directed to the removal of the 
inordinate vascular action or turgescence within the head. Some 
modifications in the mode of employing the measures mentioned, 
according to the general constitutional habit, the age, and the cha- 
racter of the exciting causes, will of course be necessary. Thus, in 
cases which succeed the sudden suppression of habitual hemorrhoidal 
discharge, some peculiar advantage may perhaps be gained from the 
application of leeches to the anus ; if the healing up of old ulcers on 
the lower extremities appears to have given occasion to the apo- 
plectic seizure, blisters, issues, or sinapisms to these parts will be 
proper ; and I have already spoken of the usefulness of emetics 
when the attack takes place soon after a surfeit, and the indispensa- 
bleness of cathartics when the bowels are loaded with feculent and 
other irritating matters. 

During convalescence from apoplexy, nothing but the lightest un- 
irritating diet should be allowed ; and unless great prostration exists, 
all kinds of vinous liquors should be interdicted. 

The prophylactic management, in persons labouring under the 
usual premonitory symptoms of apoplexy, or constitutionally pre- 
disposed to this affection, constitutes a very important point of me- 
dical attention. A simple, abstemious diet, exercise in the open air, 
and the avoidance of all kinds of stimulating drinks, as well as of 
sudden and violent mental excitement, are among the most import- 
ant precautionary measures in cases of impending apoplexy. If the 
bowels are torpid, and cannot be brought to a regular state by vege- 
table diet, it will be necessary to use an occasional dose of some mild 
laxative, as castor oil, or small portions of rhubarb; and where there 
is reason to suspect hepatic torpor or derangement, three or four grains 
of blue pill with a few grains of pulvis antimonialis, taking occasion- 
ally at night on going to bed, will be useful. When alarming pre- 

* Med Chir. Bemerkungen, b. ii, p. 109. 



PARALYSIS. 31 

monitory symptoms come on, with an active, full, and hard pulse, 
blood should be immediately drawn to an extent sufficient to reduce 
considerably the momentum of the circulation, and a brisk cathartic 
administered. It should be recollected, however, that blood-letting 
affords only temporary benefit.- A copious abstraction of blood may 
obviate an approaching attack of this disease, but frequent venesec- 
tion will do little or no good in preventing that general plethoric habit 
which is favourable to the occurrence of this affection. This must 
be done by abstemious living; and above all, by an active course of 
life. 

Persons predisposed to apoplexy from corporeal conformation, 
should be particularly careful not to interfere with, or check hemor- 
rhoidal discharges, unless they become excessive. The same pre- 
caution is necessary with regard to epistaxis in individuals of the 
apoplectic habit, as well as with other habitual evacuations. 

Drs. Cheyne* and Stokert recommend the internal/ use of small 
doses of James's powders, or pulvis antimonialis, where there is an 
habitual tendency to inordinate sanguineous determinations to the 
head. In one instance of this kind, I have known the daily use of two 
grains of James's powder, mornings and evenings, of unequivocal 
benefit. Green tea also is said to possess the power of diminishing 
or obviating cephalic congestions. Drs. E. PercivalJ and Stoker 
strongly recommended it for this purpose in comatose affections ; and 
my own experience leads me to think that it possesses considerable 
powers in this way. Coffee, however, is decidedly injurious where 
there is an apoplectic tendency. Some eight years ago, a gentleman in 
this city, of a strongly developed apoplectic habit, was seized with an 
attack of this affection. He was in the habit of taking large quantities 
of very strong coffee twice daily. I advised him to leave off taking 
this beverage entirely. He did so; and has not since experienced 
even the ordinary premonitory symptoms of the complaint. Apo- 
plectic subjects should be very careful not to bathe their feet in very 
cold water — more especially when they are subject to habitual per- 
spiration from these parts. The frequent use of the warm bath also 
is hazardous in persons of this habit ; and excessive venereal indul- 
gence is equally apt to do injury. 



Sect. II. — Paralysis. — Palsy. 

Palsy consists in impaired or abolished power of voluntary motion, 
or of sensation, or of both, in certain parts of the body, without coma, 
or a loss of consciousness. Cases in which both sensibility and the 
power of motion are at once destroyed, are however extremely rare. 
Instances even occur in which the sensibility of the palsied part is 

* Dublin Hospital Reports, vol. i, p. 315. 

f Dublin Medical Essays, anno 1806. Transactions of the Association of Fellows 
and Licentiates of the Queen's College of Physic. Dublin, vol. ii. 
% Dublin Medical Essays, vol. ii, p. 44. 



34 HEMIPLEGIA. 

became paralytic throughout nearly the whole of the muscular sys- 
tem, attended' with much torpor of the sensorial functions, and men- 
tal weakness, though wholly free from coma or somnolency.* M. 
Bretonneau has related a somewhat similar case. " A lady was 
seized with paralysis of the little linger of the left hand, which gradu- 
ally extended to the whole of that side ; the right became similarly 
affected, with the exception of the thumb and two fingers. The 
whole body was thus palsied — the tongue was motionless, and deglu- 
tition extremely difficult : but her intellectual faculties remained un- 
impaired."! Cook mentions a case, from a publication of M. Keratry, 
in which there was paralysis of the " arms, thighs, and of the whole 
exterior surface of the body, with the exception of the face." 



1. Hemiplegia. 

This is by far the most common of those forms of palsy which 
depend on oppressed function of the sensorium commune. In its 
essential pathological character, it does not appear to differ materially 
from apoplexy ; and it occurs frequently as an immediate concomi- 
tant of this disease. Hemiplegia is almost always ushered in with 
more or less distinctly marked apoplectic symptoms. 

Occasionally \he hemiplegic attack occurs suddenly, without any 
distinct manifestations of its approach. Much more frequently, how- 
ever, some of the ordinary premonitory symptoms of apoplexy pre- 
cede the attack for several days ; and just before the seizure, strong 
symptoms of sanguineous determination to the head, and cerebral 
disturbance, are particularly apt to occur — such as flushed face ; dis- 
tension of the veins about the head and neck ; vertigo ; a sense of 
fullness, weight, and sometimes pain in the head ; ringing in the ears ; 
drowsiness; impeded articulation of words, or loss of speech; slight 
delirium, or confusion of the mind ; loss of memory, and a change of 
habitual disposition. M. Serres states that he has noticed, in cases 
that came on gradually, distortion of the mouth for several hours be- 
fore the hemiplegia supervened ; and immediately before the seizure, 
he has sometimes remarked, that in the act of respiration, one side 
of the chest was quiescent, whilst the other was very conspicuously 
dilated and contracted. 

The reproductive or vital functions are seldom much disturbed in 
the ordinary cases of hemiplegia. In some instances, however, the 
whole track of the alimentary canal is extremely torpid, and it 

until I re-excited the eruptions and pruritus by the internal use of tr. guaiacum and 
external irritants. Severe pruritus continued for several years after, especially in 
his nose, and the paralysis did not return. He eventually died of hydrothorax. 
— Me.] 

* Medical Works, vol. iv ; p. 552. 

t Med. Chir. Rev., Oct. 1826, p. 604. Clinical Report of the Hospice de Per- 
fectionnement. Rev. Medicale, 1826. 



HEMIPLEGIA. 35 

would appear that the liver is sometimes affected.* The counte- 
nance generally acquires a vague or fatuous expression ; the mouth 
is drawn to one side ; the lower lip on the palsied side hangs down, 
and suffers the saliva to dribble away. Articulation is always more 
or less difficult and indistinct ; the deglutition is generally somewhat 
impeded and difficult — more especially on attempting to swallow 
liquids. It is in this form of paralysis, particularly, that the mind is 
apt to suffer from the long continuance of the disease. General im- 
pairment of the intellectual powers usually occurs ; but the memory 
is most apt to become conspicuously enfeebled, and even wholly 
effaced. 

Very remarkable anomalous circumstances are sometimes con- 
nected with hemiplegic affections. Cook has collected a great variety 
of curious cases of this kind. An instance is related, in which the 
arm of one side and the leg of the opposite one were palsied, (Fabri- 
cius;) another, where the sensibility, but not the power of voluntary 
motion, was destroyed in one leg, whilst in the other the power of 
motion was lost, with the sensibility unimpaired. (Ramazzini.) Cases 
are reported in the Memoirs of the Royal Academy of Sciences, tn 
which there was an entire loss of sensibility, without any impair- 
ment of voluntary motion. In some instances the sensibility is 
morbidly increased. Falconer mentions a case in which cold bodies 
communicated the sensation of heat to the palsied parts ; and in the 
case of Dr. Vieusseux, (Med. Chir. Trans , vol. ii, pp. 216, 217,) the 
right side was at first so insensible that it could be pinched or pricked 
without giving him pain ; afterwards this insensibility seized on 
the left side. In the right side cold bodies excited the sensation of 
heat, and hot bodies that of cold, or only coolness. Dr. Cook has seen 
a case of hemiplegia, in which the muscles of the left arm, from the 
shoulder to the elbow, were much emaciated, and greatly impaired in 
activity; whilst those of the forearm were in a perfectly natural state, 
both as to fullness and power. The condition of the right arm was 
directly the reverse; the muscles of the part above the elbow were 
natural in size and energy, but those of the forearm were wasted and 
powerless. 

In some instances little or no improvement takes place, and the 
patient remains helpless, often for a long time, and at last dies, either 
from gradual exhaustion, or suddenly from apoplexy. More com- 
monly, however, more or less amendment slowly occurs, until the 
patient is perhaps able to support himself with but little aid in a sit- 
ting posture, or even to walk about, with some assistance, without any 
further improvement. Occasionally the paralysis passes off almost en- 
tirely in a few days; but the progress of improvement is usually very 
slow and gradual, and rarely goes on at once equally throughout the 
whole of the paralyzed part. 

* Morgagni, Epist. xi. art. xiv. 



36 PARAPLEGIA. 

2. — Paraplegia. 

The palsy, in this form of the disease, is confined to the lower half 
of the body— that is, to the pelvis and the inferior extremities. When 
the immediate cause of abolished nervous function is seated in the 
upper parts of the spine, the paralysis will affect the superior parts of 
the body; but the term paraplegia is generally restricted to palsy of 
the inferior extremities, and parts about the pelvis.* 

Paraplegia generally comes on gradually, and when it arises from 
an affection of the brain, is often preceded and accompanied in its 
course by pain in the head, giddiness, drowsiness, dimness of sight, 
and impaired memory. Sometimes a feeling of heaviness and numb- 
ness is felt in the upper extremities, as a precursory symptom of this 
form of palsy. At first the patient usually experiences a slight stiff- 
ness and awkwardness in the motions of the lower extremities, which 
gradually increase until the patient finds himself unable to maintain 
the due balance of the body without the aid of a cane. As the dis- 
ease advances, " the stream of urine becomes more and more feeble, 
and at length dribbles off involuntarily." The bowels are generally 
constipated; but when the sphincter muscles of the anus become 
paralyzed, the feces are evacuated without the consent of the will. 
I have met with an instance of paraplegia, in which retention of the 
urine took place, requiring the use of the catheter five or six days be- 
fore any paralytic affection was experienced in the lower extremities. 
Sometimes the palsy is complete, the patient being unable to maintain 
even a sitting posture ; in other cases the power of motion is not 
wholly destroyed, so that with a little assistance the patient may sup- 
port himself in a sitting position; (Baillie.t) When paraplegia depends 
on disease or lesion of the spinal marrow, it usually approaches very 
gradually, unless it occurs as the immediate consequence of some me- 
chanical injury of the spine. The patient at first feels a languor and 

* [Paraplegia of the superior extremities alone, is a very rare disease. It can 
only arise from an injury, or disease of the brachial nerves, after they have left 
the spinal cord. If the cervical portion of the cord itself is injured, a paraplegia of 
all the parts below must follow. 

I have met two cases of paraplegia of the arms, both of which followed concus- 
sions from falls on the shoulders. The spinal cord could not have been seriously 
injured, or the patients could not have walked to visit me at my office. I took it 
for granted that a concussion must have been communicated to the brachial 
plexus on each side, for both arms were paralyzed. One of them was a gentle- 
man in Roxborough. the other was the late Mr. Somerdyke of this city. I will take 
some future opportunity to communicate the details of these interesting cases to 
the profession. I will now merely remark that, although relaxed and flabby at 
first, their arms became rigid, and painful in a few days, plainly exhibiting the 
development of inflammation in the brachial nerves, and converting the original 
atonic paralysis from concussion into a rigid or neuralgic paralysis from irritation 
-Mc] 

t Observations upon Paraplegia in Adults. By Matthew Bail lie M.D. in the 
sixth volume of the Medical Transactions of the London College of Physicians 



PARALYSIS PARTIALIS. 37 

weakness in the knees ; after some time a difficulty in directing the 
feet occurs, and the legs in walking are involuntarily thrown across 
each other, causing frequent tripping or stumbling. By degrees the 
insensibility and loss of muscular power in the legs and thighs become 
more and more conspicuous, until, at length, a total paralysis of these 
parts occurs. The loss of vitality is sometimes so great, that gangrene 
and sloughing of the legs ensue from the mere pressure of the parts 
against the bed. About six years ago, I met with a case of paraplegia 
in an adult, which, from the attending symptoms of cerebral disturb- 
ance, depended, I presume, on some affection of the brain. In the 
course of about ten days after the accession of the paralysis, the heel 
first, and then rapidly all the soft parts of the right leg, from the ankle 
to near the knee, became gangrenous, and sloughed off to the bones. 
Paraplegia from cerebral affections most commonly occurs after 
the forty-fifth year of age, and, according to the observations of some, 
more frequently in males than in females. That variety of paraple- 
gia which depends on disease or injury of the spine, is most common 
in childhood, and seldom comes on spontaneously after the age of 
puberty. Contrary to cerebral paraplegia, it occurs more frequently 
in females than in males.* 

3. — Paralysis Partialis. 

Every sensitive and motive part of the animal system may lose 
either its power of feeling, or of motion, or of both. In some in- 
stances the palsy is confined to a particular organ, but when the 
muscles are the seat of the affection, it generally embraces either all 
the flexors or extensors, or both, of a part or the whole of a limb. 
Some cases of partial paralysis are attended with loss only of sen- 
sorial power. Of this kind are the paralytic affections of the olfac- 
tory nerves; of the retina; of the gustatory nerves; of the auditory 
nerves ; and of the nerves of general feeling or touch. In other 
cases the palsy is confined to a deprivation of the power of motion, 
with or without the loss of sensibility, in a particular part. In some 
instances a single muscle alone is paralyzed.} Abercrombie mentions 
a case of this kind, which continued for a long time without either 
extending to other muscles or becoming better. Paralysis of the 
muscles of one side of the face is by no means uncommon, and in 
some cases the under lip only becomes thus affected. The eyelids 
also sometimes become palsied ; and a loss of the power of voluntary 
motion in the muscles of the hands, feet, fingers, wrists, legs, and 
thiglis, is of frequent occurrence. The bowels, the oesophagus, the 
pharynx, the bladder, the different sphincters, and the erector mus- 
cles of the penis, are occasionally affected with palsy; and it is not 

* Dr. C. Meigs has reported an interesting instance of paralysis of the inferior 
extremities, occasioned by the sudden repulsion of crusta ladea by some drying 
ointment. (North Amer. Med. and Surg. Joum., vol. X, p. 376.) 

t [The deltoid is especially liable to this affection. — Me.] 



38 PARALYSIS PARTIALIS. 

improbable that some of the secretory organs— particularly the kid- 
neys and liver — may sometimes be thus affected. _ t 

" Of the causes of paralysis.— The predisposing and exciting 
causes of those forms of palsy which arise from an affection of the 
common nervous centre, so far as they can be ascertained, do not 
differ from those which have already been mentioned under the head 
of apoplexy. In relation to the immediate cause of palsy, it would 
seem that so far as it is dependent on the state of the brain, it may 
be the consequence of a great variety of morbid conditions of this 
organ. 

It has been generally supposed that pressure on the brain is the 
chief immediate cause of hemiplegia. That sanguineous or serous 
effusions, and other causes producing pressure on the brain, often 
give rise to paralysis, appears to be well established. " When the 
causes which produce cerebral pressure act generally and power- 
fully,''* says Dr. Cook, "they seem to produce apoplexy, and to give 
occasion to palsy when they act partially or with less violence ; so 
that by an increase of power of the cause, palsy may terminate in 
apoplexy; and by a diminution of it, apoplexy may terminate in 
palsy." Hemiplegia is, indeed, a very frequent consequence of apo- 
plexy ; and, on the contrary, paralysis very often terminates at last 
in an apoplectic attack. It is, nevertheless, equally well ascertained, 
that both general and partial palsy may arise from cerebral affections 
wholly unconnected with any circumstances that might be supposed 
capable of exerting any pressure on the encephalon. Reasoning, 
indeed, upon the general nature of palsy, we should be led, a priori, 
to suppose that every thing which is capable of greatly disordering 
the source of nervous power, might give rise to this affection. Dr. 
Powel, in an interesting paper on the subject of paralysis from sud- 
den exposure to cold, has adduced some cases which would seem to 
show that both general and local palsy sometimes depend on a mor- 
bid condition of the nerves alone, independent of any affection of 
the encephalic mass. So far, however, as post-mortem examinations 
can throw any light upon the nature of the proximate cause of gene- 
ral paralysis, we have direct evidence that almost every variety of 
cerebral lesion and disorder may produce hemiplegia and other forms 
of palsy. We not only find this affection connected with sanguineous 
extravasation into the brain, but also sometimes with serous effu- 
sion; or with traces of recent inflammation and vascular turgescence; 
with encysted suppuration ; with induration of some portions of the 
cerebral mass; with softening of the brain, or with destruction and 
entire loss of a portion of it; and with other morbid conditions of 
this organ. (Abercrombie.) Willis states, that in cases of protracted 
palsy, he found the corpora striata in a diseased condition ; and Pey- 
rous, in one instance, found a firm tubercle, about the size of a bean, 
in the middle of the corpus striatum. (Cook.) But the most fre- 
quent morbid appearance, discovered on dissection, is organic lesion 
or injury of the cerebral substance, particularly about The corpora 
striata, thalami nervorum opticorum, and in the medulla oblongata 
or its immediate vicinity. M. Serres mentions a case of apopfexy 



PARALYSIS PARTIALIS. 39 

attended with palsy, in which every part of the brain was perfectly 
sound, except the tuber annulare, which was completely destroyed 
by a central cavity containing a clot of blood. Although some of 
these phenomena usually present themselves on the dissection of 
paralytic subjects, yet each of these morbid conditions of the brain 
not unfrequently exists without any, or with but very slight mani- 
festations of palsy. There exists also much diversity in the extent 
and particular form of the paralytic affections connected with ap- 
parently similar morbid states within the brain. In one patient, 
a particular lesion or diseased condition of the brain will be attended 
with almost universal palsy ; in andther a similar state of cerebral 
affection, with regard to its location and general character, will be 
accompanied with hemiplegia; in a third patient, perhaps with para- 
plegia ; and in a fourth one, with partial paralysis. It would appear, 
also, that in hemiplegia the immediate cause of the paralysis may be 
in the spine. Dr. Prichard has published some observations which 
render this opinion at least highly probable* Notwithstanding, 
therefore, the light which dissection has thrown on the etiology of 
palsy, we are yet far from possessing any very satisfactory or pre- 
cise information on this interesting subject. The general fact, that 
pressure or organic lesion of the brain is often attended with paralysis, 
and apparently its direct cause, is, indeed, sufficiently established; 
but the various and opposite results or phenomena just mentioned, 
assure us that our knowledge upon this subject, as in truth upon 
most other points of pathology, is but general and vague. 

What has been hitherto said relates chiefly to hemiplegia. It 
would appear that paraplegia also is frequently dependent on cere- 
bral disease. Paraplegia in adults, says Dr. Baillie, is by most 
pathologists considered as the result of some disease "either in the 
bones or ligaments of the spine, or in the cavity of the spine, most 
commonly at the loins, independently of any disease of the brain."t 
He denies the correctness of this opinion, and expresses his convic- 
tion that, like hemiplegia, this form of palsy " depends most com- 
monly in adults, in a great measure, upon disease affecting the brain 
itself." The same sentiments appear to be entertained by Mr. Earle, 
Mr. Halford and Mr. Copeland ;$ and several recent French writers 
have expressed similar views. Dr. Baillie and Dr. Abercrombie 
relate cases of paraplegia, in which, on dissection, the cause of the 
disease was discovered in the brain. In a strongly-marked case, the 
arachnoid was much thickened and opaque ; the substance of the 
brain was considerably softer than natural, attended with vascular 
congestion of the pia mater, a large quantity of serum in the lateral 
ventricles, as well as in the theca vertebralis, and between the mem- 
branes of the brain. Dr. Baillie thinks that the serum which is 
sometimes found in the theca vertebralis in this affection, descends 
into it from the brain. We cannot doubt that paraplegia may some- 

* Med. Repository, No. 1, New Series. 

t Loc. cit., p. 17. 

% Med. Chir. Rev. ; December,. 1820. p. 392. 



38 PARALYSIS PARTIALIS. 

improbable that some of the secretory organs -particularly the kid- 
neys and liver — may sometimes be thus affected. 

' Of the causes of par aly sis. —The predisposing and exciting 

causes of those forms of palsy which arise from an affection ot me 
common nervous centre, so far as they can be ascertained, do not 
differ from those which have already been mentioned under the head 
of apoplexy. In relation to the immediate cause of palsy, it would 
seem that so far as it is dependent on the state of the brain, it may- 
be the consequence of a great variety of morbid conditions of tins 
organ. . . . 

It has been generally supposed that pressure on the brain is the 
chief immediate cause of hemiplegia. That sanguineous or serous 
effusions, and other causes producing pressure on the brain, often 
give rise to paralysis, appears to be well established. " When the 
causes which produce cerebral pressure act generally and power- 
fully," says Dr. Cook, "they seem to produce apoplexy, and to give 
occasion to palsy when they act partially or with less violence ; so 
that by an increase of power of the cause, palsy may terminate in 
apoplexy; and by a diminution of it, apoplexy may terminate in 
palsy." Hemiplegia is, indeed, a very frequent consequence of apo- 
plexy ; and, on the contrary, paralysis very often terminates at last 
in an apoplectic attack. It is, nevertheless, equally well ascertained, 
that both general and partial palsy may arise from cerebral affections 
wholly unconnected with any circumstances that might be supposed 
capable of exerting any pressure on the enccphalon. Reasoning, 
indeed, upon the general nature of palsy, we should be led, a priori, 
to suppose that every thing which is capable of greatly disordering 
the source of nervous power, might give rise to this affection. Dr. 
Powel, in an interesting paper on the subject of paralysis from sud- 
den exposure to cold, has adduced some cases which would seem to 
show that both general and local palsy sometimes depend on a mor- 
bid condition of the ?ierves alone, independent of any affection of 
the encephalic mass. So far, however, as post-mortem examinations 
can throw any light upon the nature of the proximate cause of gene- 
ral paralysis, we have direct evidence that almost every variety of 
cerebral lesion and disorder may produce hemiplegia and other forms 
of palsy. We not only find this affection connected with sanguineous 
extravasation into the brain, but also sometimes with serous effu- 
sion; or with traces of recent inflammation and vascular turgescence; 
with encysted suppuration ; with induration of some portions of the 
cerebral mass; with softening of the brain, or with destruction and 
entire loss of a portion of it; and with other morbid conditions of 
this organ. (Abercrombie.) Willis states, that in cases of protracted 
palsy, he found the corpora striata in a diseased condition ; and Pey- 
rous, in one instance, found a firm tubercle, about the size of a bean 
in the middle of the corpus striatum. (Cook.) But the most fre- 
quent morbid appearance, discovered on dissection, is organic lesion 
or injury of the cerebral substance, particularly about the corpora 
striata, thalami nervorum opticorum, and in the medulla oblongata 
or its immediate vicinity. M. Serres mentions a case of apoplexy 



PARALYSIS PARTIALIS. 39 

attended with palsy, in which every part of the brain was perfectly 
sound, except the tuber annulare, which was completely destroyed 
by a central cavity containing a clot of blood. Although some of 
these phenomena usually present themselves on the dissection of 
paralytic subjects, yet each of these morbid conditions of the brain 
not unfrequently exists without any, or with but very slight mani- 
festations of palsy. There exists also much diversity in the extent 
and particular form of the paralytic affections connected with ap- 
parently similar morbid states within the brain. In one patient, 
a particular lesion or diseased condition of the brain will be attended 
with almost universal palsy ; in another a similar state of cerebral 
affection, with regard to its location and general character, will be 
accompanied with hemiplegia; in a third patient, perhaps with para- 
plegia ; and in a fourth one, with partial paralysis. It would appear, 
also, that in hemiplegia the immediate cause of the paralysis may be 
in the spine. Dr. Prichard has published some observations which 
render this opinion at least highly probable.* Notwithstanding, 
therefore, the light which dissection has thrown on the etiology of 
palsy, we are yet far from possessing any very satisfactory or pre- 
cise information on this interesting subject. The general fact, that 
pressure or organic lesion of the brain is often attended with paralysis, 
and apparently its direct cause, is, indeed, sufficiently established; 
but the various and opposite results or phenomena just mentioned, 
assure us that our knowledge upon this subject, as in truth upon 
most other points of pathology, is but general and vague. 

What has been hitherto said relates chiefly to hemiplegia. It 
would appear that paraplegia also is frequently dependent on cere- 
bral disease. Paraplegia in adults, says Dr. Baillie, is by most 
pathologists considered as the result of some disease "either in the 
bones or ligaments of the spine, or in the cavity of the spine, most 
commonly at the loins, independently of any disease of the brain."t 
He denies the correctness of this opinion, and expresses his convic- 
tion that, like hemiplegia, this form of palsy " depends most com- 
monly in adults, in a great measure, upon disease affecting the brain 
itself." The same sentiments appear to be entertained by Mr. Earlc, 
Mr. Halford and Mr. Copeland ;t and several recent French writers 
have expressed similar views. Dr. Baillie and Dr. Abercrombie 
relate cases of paraplegia, in which, on dissection, the cause of the 
disease was discovered in the brain. In a strongly-marked case, the 
arachnoid was much thickened and opaque ; the substance of the 
brain was considerably softer than natural, attended with vascular 
congestion of the pia mater, a large quantity of serum in the lateral 
ventricles, as well as in the theca vertebralis, and between the mem- 
branes of the brain. Dr. Baillie thinks that the serum which is 
sometimes found in the theca vertebralis in this affection, descends 
into it from the brain. We cannot doubt that paraplegia may some- 

* Med. Repository, No. I, New Series. 

t Loc. cit., p. 17. 

X Med. Chir. Rev. ; . December. 1820 ; p. 392. 



40 PARALYSIS PARTIALIS. 

times be entirely dependent on cerebral disease ; yet observation 
renders it equally certain that disorder, lesion, or pressure upon tne 
spinal cord is, even in adults, very frequently the immediate cause 
of the paraplegic affection ; and in children this is unquestionably 
by far the most common source of the disease. In relation to the 
disease in adults, a great number of well-authenticated dissections 
might be adduced, presenting unequivocal evidence of its spinal 
origin; and facts illustrative of this point, in reference to the disease 
in children, must be familiar to every one. It has already been 
observed, that paralysis depending on the disease of the brain, occurs 
almost universally on the side opposite to that in which the cerebral 
affection exists. Some exceptions, indeed, to this fact have been 
noticed by pathologists, but these are extremely rare. Mr. Bayle 
has collected, from different authorities, eight cases in which palsy 
took place on the same side of the cerebral affection.* When para- 
plegia depends on disease seated within the head, the primary affec- 
tion extends probably to both sides of the brain. This opinion is at 
least strongly countenanced by the phenomena developed on post- 
mortem examination. (Baillie.) 

Partial pur aly sis depends on a great variety of causes both of a 
general and local character. It may depend on disease within the 
head, on spinal affections, and disease or local injury of a particular 
nerve. The latter source of this form of palsy is probably the most 
common. Local paralysis is sometimes excited apparently by intes- 
tinal irritation in children. In cases of this kind, the palsy is usually 
confined to one of the arms.t I have seen cases of palsy of the arm 
in young children, which appeared to have been occasioned by the 
irritation of worms in the bowels. 

Much attention has, within a few years past, been bestowed on 
local paralysis of the muscles of one side of the face. It appears from 
the researches of Shaw and Bell, that this variety of palsy depends 
most commonly on some injury of the portio dura of the seventh 
pair ; and in some instances, also, on a diseased condition of that part 
of the brain which gives origin to this nerve.t The occasional causes 
of this variety of palsy are, inflammation of the ear spreading to the 
portio dura; surgical operations about the ear and consequent injury 
of this nerve; disease of the temporal bone; tumours pressing on 
this nerve; sudden exposure to cold ;§ injuries inflicted on the head; 
and disorganization and other morbid conditions within the brain, 
implicating the portio dura. The paralysis in cases of this kind is 
not complete— the muscles of the face being deprived only of « the 
power of those actions which are to a certain degree involuntary, 
and to perform which it is necessary there should be a combination 
with the organs of respiration ;" sensibility, and those actions which 
are derived from the trigeminus, namely, the action of the orbicularis 

* Revue Medicate, Janvier, 1824. 

t C. Bell. See Cook r s Treatise on Nervous Diseases, p. 268. 

% On Partial Paralysis. By John Shaw. Med. Chirurg. Transact, vol xii n 1 

§ Dr. Powell. Transactions of the College of Physicians vol. v. 



PARALYSIS PARTIALIS. 41 

oris, of the eyelids, of the buccinators, and of the muscles subservient 
to mastication remaining undiminished.* Mr. Shaw remarks, that 
in the paralysis of the face after an attack of apoplexy, just the re- 
verse condition in this respect obtains — the actions just enumerated 
as depending on the fifth pair of nerves being abolished; whilst those 
which are influenced by the portio dura remain unimpaired. 

Among the exciting causes of partial paralysis, the poisonous 
influence of lead is the most remarkable. The tendency of this 
article, in whatever way it may be brought to act on the system, to 
produce paralysis of the muscles of the forearm and wrists, is pecu- 
liarly strong, as is evident from the frequency of this affection in per- 
sons who work in lead mines, in plumbers, manufacturers of white 
lead, painters and glaziers. There exists, however, much diversity 
with regard to the constitutional predisposition of different indivi- 
duals to become thus affected by this article. Some persons appear 
to enjoy almost an entire immunity from its poisonous influence, 
although much exposed to its operation, whilst others are peculiarly 
liable to its effects. 

Paralysis of the extensor muscles of the hands and wrists some- 
times occurs, apparently from pressure of the nerves which go to 
these muscles. Cases of this kind generally come on during sleep, 
and seem to be occasioned by a particular position of the arm, while 
the head is resting upon it, and compressing, perhaps, its principal 
arteries and nerves. I met with a case lately in a young gentleman 
who fell asleep while sitting at his desk. On awaking he found that 
he could not extend the hand nor use the fingers ; the palsy continued 
for four weeks before it yielded. Dr. Healy has published an inte- 
resting paper on this variety of palsy, in the third volume of the 
Dublin Hospital Reports. 

The question why the power of motion is often entirely destroyed 
whilst that of sensation remains undiminished, has at all times greatly 
perplexed physiologists. Galen supposed that two sets of nerves 
were distributed to every part of the body — one to endow them with 
sensibility, and the other to give to the muscles the power of volun- 
tary motion. What was thus alleged from mere theoretical views 
by this very sagacious physician, has been recently demonstrated by 
M. Magendie and Mr. C. Bell. The nerves which originate from 
the spinal prolongation of the brain, and which supply the power of 

* [This is not exactly correct. The portio dura supplies all the voluntary and 
involuntary motions of the muscles of the face and brow — including the frontal, 
the corrugator, the orbicularis, the buccinator, &c. The only exceptions are the 
muscles of the eyeball, the levator palpebral superioris, and the masticators. Mr. 
Bell's original statement that the portio dura only controlled the associated or 
involuntary motions, was incorrect. The fifth pair supplies common sensibility 
alone to the forehead, eyes and face. The small anterior root of its third branch 
alone is muscular, and that supplies the masticator muscles solely. The phe- 
nomena dependent upon a partial paralysis of the portio dura correspond exactly 
with this anatomy; and the statements in the text of our author must, therefore, 
be taken with some modification. — Mc] 



42 PARALYSIS PARTIALIS. 

voluntary motion and sensibility, are composed of two packets of 
fibres proceeding from distinct parts of the spinal marrow. It has 
been ascertained that, by dividing or compressing the posterior of the 
two fasciculi by which the spinal nerves originate, the sensibility of 
the part to which the nerves go is greatly diminished, whilst the 
power of motion remains unimpaired ; and, on the contrary, if the 
anterior of these heads of the nerve be divided or materially injured, 
the power of voluntary motion is destroyed in the parts to which it 
is distributed, but the sensibility remains' unaffected. This physiolo- 
gical fact throws much light on the curious phenomenon in question, 
and may be regarded as full an explanation of it as anatomical 
investigations are capable of furnishing on any subject. 

Treatment.— The prophylactic treatment of approaching hemi- 
plegia does not differ from that which is proper for warding off an 
attack of apoplexy. In the apprehension of a stroke of palsy, a low 
diet, gentle exercise in the open air, and the avoidance of all kinds 
of stimulating liquors, as well as of full and heavy meals, should be 
enjoined ; and the bowels kept in regular motion by gentle laxative 
medicines. 

Where predisposition to apoplexy exists, and particularly when 
the ordinary premonitory symptoms of this affection occur frequently, 
a drain by means of setons or issues established in the neighbourhood 
of the head, will contribute materially in obviating the paralytic 
seizure. 

Much discrepancy of opinion has been expressed with regard to 
the value of blood-letting in hemiplegia. Some speak strongly in 
praise of its powers ; while others condemn its use as often decidedly 
injurious. An attention to the various pathological conditions of the 
brain in cases of this disease, must at once show the folly of sweep- 
ing declarations either in favour or against this measure. We meet 
with cases, for instance, in which there are unequivocal manifesta- 
tions of sanguineous engorgement in the vessels of the head ; and 
with others, in which the face is pale and shrunken, and the pulse 
small, weak, and irregular. The immediate cause may consist in 
vascular turgescence with sanguineous extravasation into the brain; 
or in a slow disorganization of a portion of this organ, with little or 
no engorgement or inordinate action of the cerebral vessels. The 
pulse, must be our guide in the employment of this evacuation. 
If the artery beats strongly, and is full and hard under the finger, 
blood should be drawn freely and promptly as in apoplexy, until the 
momentum of the circulation is adequately moderated. * When, on 
the other hand, the pulse is weak, the extremities cold, and the face 
pale and contracted, as it sometimes is in old, weak, and nervous indi- 
viduals, blood-letting to any considerable extent is just as obviously 
contra-indicated. In a few cases, I have extracted from forty to 
fifty ounces of blood in the course of twelve hours after the hemi- 
plegic attack with decided benefit; but I have met with cases also 
in which even a moderate bleeding brought on faintness and alarm- 
ing weakness, without any favourable impression on the paralytic 
affection. Of course, even where the state of the circulation indi- 



PARALYSIS PARTIALIS. 43 

cates the propriety of this evacuation, regard must be had to the age 
of the patient, his constitutional habit, and the nature of the exciting 
cause. 

Purgatives are as useful here as in apoplexy. In no instance, 
whether the action of the pulse be strong or weak, can evacuants of 
this kind be properly omitted. "All writers," says Dr. Cook, "agree 
as to the propriety of keeping the body open in hemiplegia. The 
neutral salts and other purgatives of the refrigerant kind may be 
given where there is much determination of blood to the head, and 
in full habits; but in debilitated, leucophlegmatic, and dropsical cases, 
the more stimulating purgatives, such as aloes, calomel, scammony, 
colocynth, jalap, &c, may with more propriety be administered." 
An excellent mode of giving purgatives in habits of this latter kind, 
is to administer them in combination with powdered mustard. From 
ten to twelve grains of calomel mixed with about twenty grains of 
mustard, and succeeded in about three hours by a dose of infusion 
of senna, will rarely fail in such cases to procure free and copious 
evacuations. In relaxed and sluggish habits, cathartics will almost 
always operate with more certainty and force when given with a 
stimulant of ibis kind. I have frequently, under such circumstances, 
administered a small portion of Cayenne pepper with purgatives, 
with excellent effect. 

Emetics also are much recommended by some writers in the treat- 
ment of hemiplegia. In recent instances, ushered in by apoplectic 
symptoms, and particularly in robust and plethoric subjects, they are 
of doubtful propriety. When hemiplegia comes on during a dyspeptic 
condition of the stomach, or soon after taking food of difficult digestion, 
an emetic may, no doubt, prove very serviceable. At a more ad- 
vanced period of the disease, when the momentum of the circulation 
is moderate, and no symptoms of cerebral congestion exist, emetics 
will occasionally do much good, and may be freely employed without 
risk of doing mischief. 

In addition to the general remedies already mentioned, revulsive 
applications constitute important auxiliaries in the treatment of this 
affection. In recent cases, blistering or cupping the nape of the neck, 
and sinapisms to the ankles, will sometimes contribute considerably 
to the removal of the disease. 

Stimulating enemata also are highly recommended in this variety 
of palsy ; and I have myself witnessed several instances of their good 
effects. 

In paraplegia, attended with symptoms of cephalic disorder, besides 
the local applications just mentioned, Dr. Baillie recommends the use 
of calomel, or the blue pill in union with squills, together with purga- 
tives. He directs a grain of calomel, or five grains of the blue mercu- 
rial mass with one grain of dried squills, every night for several weeks, 
with an occasional dose of one of the neutral purgative salts. 

When all the symptoms of undue determination to the head have 
disappeared, or the disease lias assumed a strictly chronic character, 
antiphlogistic and depletory remedies are no longer appropriate 
means. Exciting remedies must now be resorted to. Frictions, stimu- 



44 PARALYSIS PARTIALIS. 

lating liniments, sinapisms, blisters, stimulating baths, cold affusions, 
electricity and galvanism, are the principal external exciting applica- 
tions ; and, under proper management, they often prove decidedly 
beneficial. Frictions with the flesh-brush, or a piece of dry flannel, 
will sometimes answer better than the more irritating or rubefacient 
applications. The frictions should be made twice or thrice daily, and 
continued each time at least half an hour. Along with dry frictions, 
the occasional application of blisters to the leg and wrist of the affected 
side may prove beneficial. Where the palsy is complete, however, 
the sinapisms or blisters should not. be left on too long, lest gangrene 
and sloughing be produced. A moderate rubefacient effect is all that 
it will, in general, be prudent to excite in cases of this kind. Cullen, 
indeed, observes, that when external stimulants produce violent in- 
flammation, they are apt to do less good than when they act merely 
as rubefacients, or at most create but a moderate degree of superficial 
inflammation. Anciently, the application of nettles was much re- 
commended; and from the very pungent irritation they produce in 
the skin, they may, no doubt, be serviceable. I have known the 
application of dolichos pruriens to a paralytic limb to be of manifest 
advantage. 

Electricity, being peculiarly adapted to excite the nervous system, 
has been much employed in the treatment of paralytic affections ; and, 
under judicious management, it will sometimes do much good. I 
have known several cases of local palsy completely cured by this 
agent ; and the records of medicine furnish us with no small number 
of instances in which it was successfully employed. It would appear, 
however, that it has sometimes proved injurious. Mr. Cavallo ob- 
serves, that electricity has often proved wholly inefficacious in para- 
lysis, and in some instances, pernicious and even fatal. It seems 
probable, however, that where it has been followed by unfavourable 
or fatal consequences, it-was applied in too powerful a manner: for 
it is admitted, on all hands, that it proves most beneficial when it is 
moderately and repeatedly applied. Shocks should never be given. 
The electric fluid must be passed through the affected part without 
sparks, by means of wooden points ; or, at most, by discharging very 
weak sparks into it from the prime conductor. Dr. Cook remarks, 
that this agent " is only to be considered safe when its operation is 
confined to parts somewhat remote from the head;" and that it is 
most apt to prove injurious when the disease depends upon disease 
or compression of the brain. 

Galvanism, also, has been recommended for the cure of this affec- 
tion ; and it is said to be safer, and in general, more effectual than 
electricity. Dr. Bardsley, from considerable experience with the use 
of galvanism in paralysis, concluded, that if no sensible benefit arise 
from a steady and well-regulated application of this influence, after 
a trial of a week or ten days, its use ought to be discontinued ; that 
when the brain forms a part of the galvanic circle, it is to be' very 
cautiously employed ; and that when the activity and firmness of the 
pulse, as well as the temperature of the affected part, are increased 
the corporeal and mental feelings somewhat enlivened, and the secre- 



PARALYSIS PARTIALIS. 45 

tions improved, we may persist in the application of this agent, with 
the prospect of ultimate and permanent advantage. When the affected 
parts are so torpid as to render them insusceptible of the galvanic 
stimulus, the cuticle ought to be removed by a small blister, and the 
metallic points applied to the raw skin. (Bardsley.)* 

M. Roux has practised electro-puncturation with entire success in 
a case of paralysis of the inferior extremities. He introduced a very 
long needle (as in acupuncturation) into the spinal marrow, across the 
bodies of the vertebrae, and then connected the needle with a Voltaic 
pile. This operation has, of late, been frequently performed for para- 
lysis, chronic rheumatism, &c. Two needles may be introduced so 
as to bring the principal nerves, distributed to the affected part, within 
the galvanic circle, and bringing the needles in contact with the oppo- 
site poles of a weak galvanic apparatus. 

Moxa has been used with success in paralysis. Dupuytren has 
reported a case of general paralysis, in which moxa applied on each 
side of the spine, near the first and second dorsal vertebrae, procured 
immediate benefit. Larry mentions a case of palsy from disease of 
the spine, which was cured by thirty-two applications of moxa; and 
two other cases of paralysis of the forearm from gun-shot wounds 
yielded completely to this remedy. He also states that he cured 
several cases of paralysis of the muscles of one side of the face from 
cold, by the application of moxa; but he observes that the application 
of moxa to this part is dangerous, unless the cones of cotton are small, 
and suppuration be prevented by the application of ammonia.t The 
instances on record of the successful application of moxa in paralysis 
are, indeed, sufficiently numerous to entitle this remedy to particular 
attention in the treatment of this affection. 

Internally a variety of remedies have been recommended for the 
cure of this disease. Among these the mix vomica, or its prepara- 
tion strychnine, has of late years been a good deal used in palsy, and 
occasionally with decided benefit.^ Mr. Purcell has recently reported 
a case of paraplegia, in which this article, in conjunction with the ap- 
plication of moxa, was successfully used.§ Professor Giddings, of the 
University of Maryland, has also reported several highly interesting 
cases, which yielded to the influence of the strychnine. One of these 
cases was manifestly the result of sanguineous extravasation into the 
brain, as its accoption was attended with decided apoplectic pheno- 
mena. The second was a case of general paralysis, and the conse- 

* Medical Reports, p. 183. Cook, 1. c. p. 296. 

t Recueil des Memoires de Chirurgie, par le Baron D. L. Larrey, p. 94. 

% Decandolle, Husson, Dumeril, Lescure, Asselin, Magendie, Bricheteau, and 
Fouquier, have reported cases of palsy in which the happiest effects were pro- 
duced by the use of this remedy. M. Fouquier gave the mix vomica to the extent 
of from four to twenty-four grains of the powder daily to an habitual drunkard 
affected with hemiplegia from apoplexy; and in the course of one month he was 
entirely cured. 

$ Medico-Chirurg. Rev., November, 1829, p. 203. — Prov. Med. Gazette, No. XI, 
July, 1829. 



46 PARALYSIS PARTIALIS. 

qucnce, as was believed, of the injurious influence of lead. This 
article may be given in doses of from one-sixteenth to one-sixth ot a 
grain, three times daily. The dose should, at first, be small, and gra- 
dually increased to as" much as the system will bear. Since the last 
edition of this work was published, I have employed this powerful 
narcotic with complete success, in an obstinate and long-standing case 
of hemiplegia. It is undoubtedly a remedy of excellent powers in 
paralytic affections. When the peculiar convulsive motions which 
result from the operation of this narcotic, appear early in the palsied 
limb, in connection with transient tremors, formication, and free 
perspiration in this part, and particularly if these affections do not 
directly pass to the sound parts, the prospect of benefit from this 
remedy is said to be considerable. In paralytic affections connected 
with an inflammatory or congested condition of the brain or spinal 
marrow, and in hemiplegia from sanguineous extravasation into the 
cerebrum, this remedy cannot be employed without considerable risk 
of injurious consequences. From two to four grains of the nut may 
be administered three or four times daily, until spasmodic motions of 
the extremities ensue, or gastric distress is experienced. The extract 
is given in doses of from two to three grains ; and of the strychnine, 
which has latterly been used, one-sixth of a grain may be exhibited 
thrice daily. 

Somewhat analogous to the nux vomica is the rhus toxicodendron 
in its occasional effects in paralytic disorders. This article was for- 
merly highly extolled for its remedial powers in affections of this kind, 
and in Germany it has lately again attracted considerable attention 
in this respect.'* In two instances of hemiplegia, I prescribed the 
saturated tincture of the leaves of the rhus with unequivocal benefit. 
In a letter to me from Professor Osann, of Berlin, I am informed that 

* M. Dufresnoy, Professor of Botany at Valencia, was, I believe, the first who 
used the rhus toxicodendron in palsy, (a) Mr. Alderson, an English physician, next 
published a small work on the medical effects of this article, in which he relates 
seventeen cases which w T ere more or less benefited by its use. Dr. Horsefield, in 
his inaugural dissertation on different species of rhus, published in this city in 
1798, testifies to its usefulness in paralytic affections. Mangrat (Journ. de Phys. 
Chim. d'Histoir. Nat., vol. li, p. 370). Elz. (Dissert, de Toxicodend., 1800), Hu- 
nold (Piepenbrings' Archiv. f. Pharmacie, bd. i. st. iii, p. 276), Kok. Van Mons. 
Augustin (Asklepeion, 1811, No. IV. s. 57), Sybel (Asklepeion, 1811, No. 
XXXII, p. 497), Gisovius (Rust's Magazine, bd. xiv, s. 386), D'Alquen 
(Harles Rhein-Westphal. Jahrb. ect. bd. x, st. i. s. 135), Osann (Hufeland's Bib- 
lioth. d. Heilkund, 1823, Mai, s. 324), Buchheim (Allgem. Med. Anna!., 1825), 
Hennin (Archiv. fur Med. Erfahr. V. Horn., ect. 1823, Nov. and Dec, s. 392), 
have all published cases illustrative of the remedial powers of this article in dif- 
ferent forms of palsy. 

(a) [Dr. Senter, of Rhode Island, first introduced the rhus toxicodendron to 
the notice of the profession ; and his experience, originally published before the 
American Revolution, w-as afterwards noticed in Duncan's Medical Commenta- 
ries. — Me.] 



PARALYSIS PARTIALIS. 47 

the following mixture has been used with decided benefit at the Poly- 
clinic Institute, in paralysis of the lower extremities: 

U — Tinct. rhois. toxicodend. ^ss. 

aconiti 

guaiaci volat, 5a 31L — M. S. Take forty drops every three hours. 

The effects of this article are often very similar to those which 
result from the full operation of the mix vomica. In one of the cases 
in which I used it, the patient experienced occasional convulsive ac- 
tions in the muscles of the palsied limb, with a sensation of tingling 
or prickling in the affected part. The powdered leaves may be used, 
commencing with half a grain, and gradually increasing it to four 
grains, three times daily. The effects of this article, when given in 
large doses, are headache, vertigo, nausea, and sometimes profuse 
diarrhoea, and when these manifestations of its operation ensue, its 
use must be discontinued. 

The oil of turpentine is strongly recommended by Dr. Prichard, 
(Med. Repos., No. 1, New Series,) in paralytic affections, after deple- 
tory measures have been adequately pursued. He gives it in doses 
of from one to two drachms, three times daily. Mr. Mansoa has 
related several striking instances of the successful use of iodine in 
paralytic affections.* 

The Jlores arnicx appear to have been frequently used with entire 
success in cases of this kind. They are said to be particularly useful 
in paralysis of the bladder,t and in local palsies of the organs of sense. 
Richter, indeed, says that they may be used with occasional success in 
almost every variety of palsy. Hufeland states that he cured a case 
of scrofulous deafness with this article, in conjunction with antimo- 
nials.t Within the present year I prescribed this remedy in an in- 
stance of hemiplegia, which came on very gradually in an elderly 
female, and its effects were very manifestly beneficial. § 

The internal use of mustard seed, and of horse radish, has also 
been recommended in paralysis ; and I have known the former of 
these articles prescribed by the late Dr. Barton, in the Pennsylvania 
Hospital, with much advantage. A number of other remedies are 
said to have been employed with success in various forms of palsy. 
Cantharides in substance, " in the dose of one grain to a scruple of 
volatile salt, and gradually increased to two grains of the former and 
forty of the latter, every three hours," have been employed with 
great benefit. (Cook, Med. Comment., vol. xiii, p. 96.) Dahlberg 
and Kolpin speak highly of the effects of the tincture of colocynth,\\ 
in doses of ten drops every two hours, and gradually increased to 
sixty or seventy drops. This tincture is said to be particularly useful 
in paralysis of the inferior extremities, and of the bladder. Kolpin 
declares that he has used this remedy with extraordinary success ; and 
many other authorities of respectability might be cited, in favour of 

* Medical Researches on the effects of Iodine, &c— Lond., 1825, pp. 87-90. 

t Hufeland's Journal, bd. ix, st. iii, p. 95. % Ibid., bd. xxxiv, st. v, s. 33. 

$ The arnica is highly extolled for its virtues in paralytic affections by Junker, 
Colin, Plenck, and others. (Cook.) 

I! Hufeland's Journal, bd. ii, st. iv, p. 570. 



48 PARALYSIS PARTIALIS. 

its occasional efficacy in this affection. (Horn's JJrchiv., 1804.) The 
chenopodium ambrosiodes is said to have produced excellent effects 
in aphonia from paralysis of the muscles of the larynx.* It is given 
in substance, in doses of from a scruple to half a drachm, twice or 
thrice daily. Jahn (Klinik. der Chron. Krank., b. i, p. 365), says the 
belladonna is one of the most efficacious remedies in paralysis. Be- 
sides the foregoing remedies, almost every active tonic and stimulant 
has been recommended in such affections— phosphorus, camphor, 
volatile salts, valerian, bitters, chalybeates, the essential oils, savin, 
&c, have all found advocates as remedies in paralytic affections, but 
they deserve little or no attention in this respect. 

In that variety of local palsy which arises from the poisonous in- 
fluence of lead, the use of mercury, so as to produce moderate ptya- 
lism, in conjunction with the repeated application of blisters, or other 
active irritating substances to the wrists, and the use of the splint or 
battledore, recommended by Dr. Pemberton,t with mild aperients, and 
occasional warm bathing, constitute our most useful remedial means. 
Dr. Gregory is not willing to attribute any powers to mercury against 
this affection, notwithstanding the authority of Dr. Clutterbuck in its 
favour. I have met with one case in which gentle salivation, with 
local stimulants to the palsied parts, succeeded in removing the dis- 
ease. It is not improbable, however, that the chief advantage in this 
instance was derived from local irritating applications.^ 

In paralysis of the tongue, we may direct the patient to chew the 
root pyrethrum, or other irritating and pungent substances; such as 
cloves, senega, squills, pepper, calamus aromaticus, &c. The oil of 
cajeput has also been recommended in this variety of local palsy. A 
few drops of it are to be put on the tongue three or four times daily. 
Blisters, or frictions with tartar emetic ointment under the chin and 
ears, may also be used ; and a very moderate excitation of the tongue 
by the galvanic influence; which may be done by two flat pieces of 
silver and copper, the one applied to the upper, and the other to the 
under surface — the parts projecting from the mouth being brought in 
frequent contact. In partial paralysis of the face, cupping, leeching, 
and blistering over the origin of the portio dura, mercurial purgatives, 
and a seton in the neck, may be accounted the most efficient remedial 
measures. Dr. Delafield, of New York, has related several instances 
of this affection, which yielded under the employment of these reme- 
dies^ I have known a case of this kind, produced, or at least accom- 
panied, with indurated swelling of the parotid gland, cured by the use 
of iodine. 

* Borries — Ibid., bd. xiv, st. ii, p. 201. 

f This consists simply in applying a carved splint to the inner side of the arm, 
so that the broad surface supports the hand. 

% A gentle mercurial action is recommended for the cure of this variety of palsy 
by Hunter and Dr. Clarke. Dr. Clutterbuck regards it as the most effectual means 
we possess in this affection. 

$ New York Med. and Phys. Journ., Dec, 1834. 

II [The portio dura nerve is frequently affected by the influence of a current ot 
cold air, so as to produce a muscular paralysis at the side of the face and forehead. 



EPILEPSY. 49 



Sect. III. — Epilepsy. 

Epilepsy, whether considered in its immediate phenomena or in its 
remote consequences, is unquestionably one of the most distressing 
and deplorable of human maladies. Its tendency to impair the un- 
derstanding, to produce hebetude, and even total abolition of the 
rational powers, leads often to a condition infinitely more lamentable 
than death itself. So frightful and distressing a disease could not fail 
to attract the particular attention of the physicians of every age; and 
we accordingly find it minutely described, and its nature and treat- 
ment extensively discussed, in the works of the Greek and Roman 
physicians.* 

The soporose and convulsive affections are so closely allied to each 
other, both in relation to their general phenomena and their patholo- 
gical character, that it is extremely difficult to give an unexception- 
able definition of any of them. Epilepsy may, perhaps, be defined 
a disease primarily seated in the nervous system, manifested by con- 
vulsions recurring at uncertain periods in paroxysm, accompanied by 
a temporary loss of consciousness, sense, and voluntary motion, and 
terminating in somnolency. 

The epileptic attack sometimes comes on suddenly without any 
manifestations of its approach. More frequently, however, certain 
symptoms precede the occurrence of the paroxysm, and of these the 
following are the most common: — A peculiar confusion and distress- 
ing feeling in the head ; an absent, wandering, and confused state of 
the mind ; giddiness ; dimness of sight ; ringing and loud sounds in 
the ears ; sparks and flashes of light before the eyes ; distension of 
the veins of the head and neck ; a trembling and feeling of restless- 
ness in the extremities; an anxious feeling in the precordial region ; 
restlessness and starting during sleep ; loss of the power of distinct 
articulation ; complete temporary deafness, and drowsiness. In some 
instances, there is a manifest change in the moral disposition a short 

I have known patients afflicted with it on coming up from a damp cellar, and then 
their friends became alarmed at the distortion of the countenance and indulged the 
fears of an apoplexy. I have always succeeded in curing this form of palsy in a 
few days, by diaphoretics and counter-irritants. Enveloping the whole face and 
side of the head in carded cotton and rubbing croton oil occasionally over the 
course of the nerve, will generally afford speedy relief. — Mc] 

* Hippocrates describes epilepsy under the name of morbus sacer — a name which 
was given to it from its supposed origin; it being generally regarded at his day, 
as an infliction of the gods or of demoniac influence. Aristotle treats of it under 
the name of morbus Herculius, because Hercules is said to have been afflicted 
with this disease. The most common appellation of this affection among the 
Roman physicians, however, was morbus comitialis. We nevertheless find it 
mentioned also under various other names in their writings — such as morbus sonti- 
ctis, morbus caducus, morbus puerilis, m jrbus insputatus, seleniacus, major, magnus, 
vitriolatus, mensalis, &c. In the sacred writings, epileptic persons are called 
lunaticos. 

VOL. II. — 5 



50 



EPILEPSY. 



time before the accession of the attack. Sullen gloominess with an 
irritable temper is manifested by some patients. In some cases, the 
mind falls into a kind of reverie from which it cannot be drawn, which 
terminates often speedily in total insensibility. Some epileptics evince 
an unusually timid disposition ; others are spiteful, resentful and mis- 
chievous, shortly before the accession of the paroxysm. Occasionally, 
spasmodic twiches of particular muscles, especially in those of the 
face, precede the attack. Richter states, that painful sensations in 
certain parts of the body, particularly spasmodic pains in the stomach, 
with a rumbling noise in the bowels, occur as the precursors of the 
epileptic paroxysm. 

The most remarkable of the premonitory symptoms of epilepsy, 
however, is that which is technically called aura. The sensation to 
which this term is applied, and which, I believe, occurs in no other 
disease, is compared by patients to the feeling which is communicated 
by a gentle stream of cool air directed on the part. This sensation 
generally commences in the feet or legs, and gradually ascends until 
it reaches the head, when the patients instantly become insensible and 
epileptic. Some patients are enabled by this symptom to tell with 
accuracy the nearness of the attack, and to avail themselves of this 
intimation to place themselves in a situation in which they will be 
less liable to sustain injury during the attack. Spiculae of bones, 
tumours, and foreign bodies pressing upon and irritating some nerve, 
have been found to exist at the starting point of this singular sensa- 
tion.* The primary irritation is, however, almost invariably seated 
elsewhere, and transferred sympathetically to the part in which the 
aura commences. 

In many instances, the attack always occurs at night while the 
patient is sleeping. In this respect epilepsy differs conspicuously from 
chorea, the convulsive motions of which, however violent during the 
day, are almost always wholly suspended during sound sleep. 

When the epileptic seizure occurs while the patient is sitting or 
standing, he suddenly falls down in a state of insensibility, and im- 
mediately becomes more or less violently convulsed. In some cases, 
the convulsive actions of the muscles, particularly those of the face, are 
frightfully violent ; the whole frame is violently agitated ; the eyes roll 
about ; the lips and eyelids are convulsed ; the tongue often spasmo- 
dically thrust from the mouth, which, with "gnashing of the teeth, 
and foaming at the mouth, give the countenance a horridly wild ex- 
pression." Sometimes the teeth are firmly pressed together ; at others, 
the jaws are widely and fixedly distended ; the thumbs are almost 
invariably firmly pressed in upon the palms of the hands. The spasms 
are generally of the clonic kind ; but in some instances, the muscles 
remain for a time rigidly contracted, the body being bent either back- 
wards, forwards, or to one side, as in tetanus. Occasionally, the 
abdominal muscles are violently drawn in towards the spine. In 
many instances, there are strong erections of the penis, with spas- 
modic retraction of the testicles, and occasional seminal discharge. 

* Van Swieten's Commentaries, vol. iii, p. 419. — See also Medical Experiments 
and Observations by a Society, &c, at Edinburgh, vol. iv, p. 334. 



EPILEPSY. 51 

(Richter.) The face is occasionally pale, but more commonly livid 
with a turgid state of the veins of the head and neck. The heart 
palpitates rapidly; the pulse is usually contracted, irregular and fre- 
quent ;* and respiration oppressed, laborious, and, in violent cases, 
sonorous. About the termination of the paroxysm, a considerable 
quantity of frothy saliva usually flows from the mouth; and in some 
cases, the feces and urine pass off involuntarily. Sooner or later these 
spasmodic symptoms abate — generally gradually, but sometimes ab- 
ruptly. The respiration becomes freer ; the pulse fuller and more 
regular; the countenance more composed; and the patient finally 
falls into a state of stupor or deep sleep, out of which he awakens with 
a feeling of languor, and confusion and torpor of mind, which gene- 
rally continues for ten or twelve hours. The countenance exhibits a 
vacant and stupid expression, and the eyes are dull, staring and wan- 
dering. In violent attacks the mind remains obtuse and fatuous, and 
the temper irritable and morose, for several days after the paroxysm. 
During this somnolent state, the patient usually perspires freely, par- 
ticularly about the head, neck, and breast ; and the perspiration has 
frequently a very peculiarly offensive smell.t The sweating has 
been known to be distinctly confined to one side of the body only.f 
Epilepsy does not, however, always assume the violent grade just 
described. Sometimes the attack supervenes suddenly, and after a 
few moments of partial convulsions of the muscles of the face and 
neck, quickly subsides, and restores the patient to consciousness. I 
once attended a girl affected with this disease in so slight a manner 
that the convulsions seldom lasted longer than a few minutes. 

In relation to the duration of the epileptic paroxysm, there exists 
great diversity. The convulsive stage generally continues from ten 
to fifteen minutes, sometimes for half an hour, and occasionally for 
several hours. The paroxysm is most apt to become protracted in 
children. In most instances one paroxysm only occurs at a time. 
Sometimes, however, they recur several times — the patient passing 
from one to another, with but a very short interval between them. 
In general, the first attacks are shorter than those which occur after 
the disease has continued for some time. The contrary, however, 
generally takes place when the first attack is caused by some sudden 
and violent mental impression, as terror. 

With regard to the interval between the epileptic seizures, also, 
there exists the greatest diversity. In some cases the paroxysm re- 
turns almost daily ; in others at various intervals, from a few days to 
a whole year. Many instances observe a more or less perfect peri- 
odicity in the recurrence of the fits ; whilst others are quite irregular 
in this respect. Richter observes, that cases arising from gastric or 
intestinal irritation, and from catamenial irregularities, are most apt 

* Dr. Burnett relates a singular case of epilepsy, in which the pulse became go 
slow at times as to beat only fourteen strokes in a minute. — (Med. Chir. Transact., 
vol. xiii, part i, p. 202.) Morgagni relates two similar cases. 

t De Haen, Ratio Medend., torn, v, p. 123. 

% Voigtel's Handbuch der Patholog. Anatom., b. i ; p. 70. 



52 



EPILEPSY. 



to assume a periodical character.* Occasionally the paroxysms recur 
regularly at the periods of new or full moon. Nearly twenty years 
ago I treated a case successfully, in which for several years previously 
the paroxysms had returned regularly on the night of each full moon. 
Examples of this kind may, however, occur as mere coincidences, 
without any relation, as cause and effect, between the two pheno- 
mena. t 

Epilepsy seldom proves fatal, except through the intervention of 
apoplexy. When it recurs very frequently, however, the mental 
powers gradually fail, until at last a total imbecility or idiotism is 
induced. The most complete state of idiotism 1 have ever seen, 
was produced in less than two years, in a fine, intelligent boy, by 
the ferocious attacks of this malady. 

Post-morlem appearances. — The morbid appearances discovered 
on dissecting subjects who die of epilepsy, are often similar to those 
which occur in apoplexy and palsy. No man has, perhaps, dissected 
so great a number of bodies that had died of epilepsy as M. Wentzel. 
Previous to the dissections of this indefatigable anatomist, it was 
generally thought that the cerebrum is the chief seat of the proxi- 
mate cause of epilepsy. M. Wentzel, however, in a very great pro- 
portion of heads he examined, found the cerebrum perfectly sound, 
whilst the cerebellum was uniformly in a diseased condition.! The 
part of the cerebrum which he found most frequently affected, was 
the pineal gland. The cerebellum was generally of a dusky red, 
approaching to a blackish colour; in some cases it exhibited a 
whitish or yellow hue, and in a few instances the posterior lobe was 
of a gray colour. This portion of the encephalon was sometimes 
very soft ; more frequently it presented a preternaturally hard and 
compact structure. In ten out of twenty-one cases, a morbid, yellow, 
friable matter was found between the lobes of the cerebellum, which 
in some instances not only separated the lobes, but caused also the 
destruction of a portion of their substance. Notwithstanding these 
observations of Wentzel, dissections made by other pathologists 
render it certain that the substance of the cerebrum is often mate- 

* Specielle Therapie, bd. vii, p. 570. 

f For a full discussion of this point, the reader may consult Mead, de Imperio 
Solis et Luna? in Corpus Humanum; also, Balfour on Sol-lunar influence. That 
the moon governs the epileptic paroxysm, appears indeed to be a very ancient 
opinion. Galen, Aretaeus, and Alexander Trallianus entertained this opinion. 
(Cook on Nervous Diseases.) 

% [Mr. Solly has discovered the connection of fibres between the cerebellum 
and the anterior fasciculus of the spinal cord, and similar commissures can be 
traced from the same column to most parts of the cerebrum. The involuntary 
control of the passions and propensities over the muscular powers can thus be 
explained, and also the influence of irritation and organic lesions of these fibres 
in the way of developing the paroxysms of epilepsy. The intellectual powers 
are supposed to be chiefly affected by derangement of the cineritious or pulpy 
substance of the brain, while the muscular system is influenced by the medullary 
fibres which are connected with its spinal apparatus of muscular motion. Mel 



EPILEPSY. 53 

rially diseased in epilepsy. This, indeed, Wentzel does not deny, but 
his observations convinced him that it is much less frequently the 
case than we might be led to believe from the observations previously 
published on this subject.* Both Gredingt and Roederer relate cases 
in which the cerebrum was disorganized to a greater or less extent. 
Some French pathologists have pointed out various morbid appear- 
ances of the mucous membrane of the intestinal canal as being inti- 
mately concerned in the causation of this disease. 

Causes. — Observation has informed us that in some cases of this 
disease the original exciting cause is seated within the head, or acts 
directly on the cerebral mass ; whilst in others the cause is located 
in some other part of the system, and affects the encephalon second- 
arily, through the medium of the nerves. It is evident, therefore, 
that we may with propriety divide this malady into two general 
varieties — namely, into idiopathic and symptomatic. Experience 
has shown that the latter is in general much more apt to yield to 
remedial treatment than the former. 

In some individuals there appears to exist a constitutional predis- 
position to epilepsy; and it is, without doubt, in some instances, of 
hereditary origin. Boerhaave mentions an instance in which all 
the children of an epileptic father died of this disease \% and Stahl 
has related a similar occurrence. § Tissot also mentions a remark- 
able instance of this kind. An epileptic man had eight sons and 
three grandsons, all of whom, he says, became affecied with this 
disease. (Cook.) 

Children, it has been observed, are much more liable to this dis- 
ease than adults; but the age at which there appears to exist the 
strongest predisposition to epilepsy is the period of puberty. Some 
writers assert that females are more subject to this affection than 
males ; others, however, contradict this assertion. Probably hysteria 
has been frequently mistaken for epilepsy, which may have given 
rise to this opinion. Those who have once had this disease, and 
have been freed from it by remedial treatment, generally retain a 
particular predisposition to its recurrence. 

The exciting causes of epilepsy are exceedingly various. Of these 
causes some act immediately on the brain, and others make their 
impressions on distant parts, and affect the sensorium commune 
secondarily through the medium of the nerves. The most common 
of the former variety of causes are ; injuries and malformation of 
the cranium; exostosis from the internal surface of the bones of the 
skull ; spiculae of bones driven in upon the brain; preternatural dis- 
tension of the cerebral vessels ; various organic affections of the brain, 
and effusions of different kinds within the cranium. (Cook.) 

* Cook on Nervous Diseases, &c., p. 342. 

t Sammtliche Medic. Schriften, ii. Theil. 

% Pralectiones in Prax. Med., torn. v ; p. 30. 

$ De Hereditar. Di.spos. ad Varios Affectus. Halle, 1706, p. 48. Also in his 
Dissertatio de Epilepsia Hereditaria Casum Exhibens, as quoted in Richter's 
Specielle Therapie, bd. vii, p. 594. 



54 



EPILEPSY. 



Sudden and violent mental emotions frequently produce this dis- 
ease by a morbid excitement originating in the brain. Fear, terror, 
grief, and other disagreeable sensorial and mental impressions, have 
been known to give rise to epilepsy. I have met with three instances 
that were excited by terror. Locker states that six out of fourteen 
cases of this disease, which came under his care in the Hospital St. 
Mark at Vienna, were produced by terror. Many remarkable in- 
stances of epilepsy, excited by disagreeable and strong impressions 
on the senses, have been reported. Strong odours, sudden and vivid 
light, loud and peculiar sounds, and certain colours, have produced 
this disease in weak and irritable habits. Weikart relates the case 
of an individual in whom the smell of red beets excited epileptic 
paroxysms. 4 * The odour of the garden ranunculus has also given 
rise to this disease ;t and Cook quotes from Buchner an instance of 
an epileptic child in whom the sight of a vivid red colour seldom 
failed to excite a paroxysm of the disease. Cases of this kind are of 
course connected with idiosyncrasies by which the influence of these 
exciting causes is peculiarly favoured. 

This disease has frequently been excited by the sight of a person 
affected with the epileptic paroxysm. Dr. Rush mentions several 
instances of this kind. The principle of association exerts indeed a 
powerful influence over the actions of the animal economy ; and in 
no disease has this been more strikingly exemplified than in the 
present one. The mere recollection, or sight of the causes or cir- 
cumstances which attended the first attack of the disease, has re- 
excited the paroxysm.! 

Among the causes of this disease that act upon the brain through 
the general system, gastric or intestinal irritation is perhaps the 
most common. Epilepsy from this cause is most frequently met 
with in children. Worms, and indeed every other substance which 
is capable of producing an irritation in the nervous extremities of 
the mucous membrane of the alimentary canal, may give rise to this 
affection in weak and irritable subjects. A protracted case is re- 
lated, which ceased entirely after the expulsion of a tape-worm.§ 
Leeches swallowed into the stomach have produced epilepsy. (Gu- 
denklee.) 

The suppression of habitual evacuations, whether sanguineous or 
serous is another powerful exciting cause of epilepsy. Suppressed 
or morbidly postponed catamenial discharge soon after the age of 
puberty, is particularly apt to give rise to this affection in individuals 
otherwise predisposed to it.|| The healing up of old ulcers, setons, 
issues, &c., may give rise to epilepsy. Richter mentions the sup- 

* Hufeland's Journal, bd. xii, st. i, s. 174. 

t Acta. Natur. Curios., Dec. hi, Ann. ix, x, Obs. 92, p. 170. 

% Van Swieten, Commentar., torn, iii, p. 414. 

$ Mursinna's Journal, f. Chirurg. Arzneik. u. Gebershuife, b. i ; st. ii, p. 306. 
(Richter.) 

II Falk, Dissert, de Epilepsia, s. Motib. Convuls. Virgin. See also the interesting 
observations of Prichard on this subject in his Treatise on Nervous Diseases. 



EPILEPSY. 55 

pression of habitual sweating of the feet as a strong exciting cause 
of this and other convulsive affections. The repulsion or sudden 
drying up of chronic cutaneous eruptions, particularly the itch and 
tinea capitis, also may produce epilepsy; and in the exanthemata, 
either just before the eruption is about coming out, or from its sud- 
den retrocession, this form of convulsive disease is by no means 
uncommon. 

Excessive evacuations are also among the exciting causes of epi- 
lepsy ; and this is particularly the case with inordinate seminal 
evacuations, either from excessive venery or masturbation.* 

Various poisons, more especially of the narcotic kind, sometimes 
produce this disease. It is said that in Kamschatka, epilepsy is 
frequently occasioned by the use of an indigenous species of toad- 
stool, which the inhabitants of that country are much in the habit of 
eating on account of its exhilarating effects.! The abuse of opium 
in children has a tendency to produce this malady; and among the 
mineral poisons, lead and arsenic are said to be most apt to excite it. 
Wendt mentions a case produced by lead, and Dr. Warren relates a 
fatal case produced by this poison. (Cook.) In the second volume 
of the Medico-Chirurg. Transactions, five cases are reported which 
arose from the reception of arsenic into the stomach. 

The habitual intemperate use of alcoholic liquors is a very common 
cause of epilepsy. It is probable that epilepsy from this cause pro- 
ceeds from the combined influence of hepatic disorder, and a constant 
preternatural determination of blood to the brain. Painful dentition, 
pregnancy, and parturition occasionally excite the disease. Tissot 
relates three cases which arose evidently from pregnancy. In one 
case, the patient was affected with epileptic paroxysms almost every 
week, in three of her pregnancies, until quickening commenced. 
Irritation from biliary concretions, as well as from urinary calculi, 
has sometimes given rise to this affection. Dr. Cook refers to the 
works of Bertholini for examples of this kind. 

Habitual tendency to congestion or plethora of the vessels of the 
brain is perhaps one of the most frequent exciting causes of the 
epileptic paroxysm. This may be the result either of a constitutional 
habit, or of the operation of some one of the foregoing exciting 
causes, particularly intestinal irritation, and suppressed sanguineous 
and serous discharges.! Atmospheric influences also have been sup- 
posed capable of exciting this disease. Great heat or cold, and sud- 
den vicissitudes of temperature, are mentioned as exciting causes; 
but their influence in the production of this affection is perhaps 
rather predisposing and exciting. 

On the subject of the proximate cause of epilepsy, a very great 
diversity of opinion has been expressed. Without entering into a 

* Zimmerman on Experience, vol. iv, chap. 10. 

t Langsdarf in d. Weterau6chen Annalen. bd. ii, hft. 2, (Richter, Spec. Ther.) 

% [The inhalation of the vapour of sulphuric ether to produce the effects of 

nitrous oxide, has produced the worst form of congestive epilepsy f have ever 

seen. — Ma] 



56 EPILEPSY. 

detail of these opinions, ail of which are hypothetical, and many of 
them absurd, I shall content myself with a statement of those cir- 
cumstances which experience and observation appear to sanction in 
relation to the pathology of this affection.* 

1. The immediate cause of the epileptic paroxysm, whatever its 
essential character may be, is always seated in the brain. 

2. In the majority of fatal cases, organic and other obvious affec- 
tions of the brain, particularly of the cerebellum, or of the meninges, 
are found on dissection, and which, we may infer, contributed to the 
excitation of the epileptic paroxysms. 

3. The cerebral affection is in some instances primary, and the 
result of causes that act directly upon the brain. In others, proba- 
bly in the majority of cases, it is secondary, depending on primary 
irritations located remotely from the brain. 

4. Immediately before the accession of the epileptic attack, it 
would seem that vascular turgescence takes place in the encephalon ; 
and the pressure thus created, in co-operation with the general pre- 
disposition to the disease and the organic cerebral affection, where 
such disorder exists, is probably the immediate exciting cause of the 
paroxysm. 

It would be useless to enter into any discussion concerning the 
causes of the paroxysmal character of this affection, or of the occa- 
sional strict periodicity of its recurrence. The influence of habit 
lias been adduced in explanation of these mysterious points of pa- 
thology. The term habit, however, in a physiological sense, can 
mean nothing else than a tendency to repeat an action, whether 
morbid or healthy, that has been produced by some exciting cause, 
without the presence or further co-operation of such cause. This, 
however, is merely expressing the general fact, and offers no ex- 
planation of it whatever. 

Diagnosis. — The affection with which epilepsy is most liable to 
be confounded, is hysteria, when this disease assumes the convulsive 
form. They may be distinguished from each other, however, by the 
following circumstances. In hysteric convulsions, the countenance 
is less livid and distorted than in epilepsy; and there is seldom any 
foaming at the mouth, or profuse discharge of saliva, nor does it 
terminate in heavy sleep, or in a confused and torpid state of the 
mind, so general at the conclusion of the epileptic paroxysm. In 
hysteria, too, there are always some concomitant phenomena which 
indicate its character, such as the globus hystericus, involuntary 
laughing or weeping, and in many instances a continuation of some 
degree of consciousness, &c. 

Prognosis. — Although the immediate danger of the epileptic pa- 
roxysm is not in general very great, yet in relation to its sanability 
the prognosis is always highly unfavourable. Even where a cure or 

* Mr. Mansford, in a work published on epilepsy a few years ago o-i ve s it as 
his opinion, that the proximate cause of this disease consists in an°accumulation 
of the electric matter in the brain, or what he considers the same thing a super- 
abundance of the nervous power in the sensorium commune. 



EPILEPSY. 57 

suspension of the disease has been effected, the liability to a relapse 
is always considerable. When epilepsy depends on organic disorder 
within the head, no remedial management can effect a cure. Epi- 
lepsy, however, unconnected with cerebral lesion, may sometimes be 
cured.* That variety of the disease which occurs in young females 
about the age of puberty, from menstrual irregularities, is not unfre- 
quently curable, and indeed sometimes passes off spontaneously after 
the catamenia begin to flow regularly. The longer the disease has 
continued, or rather, the more frequently its attacks have been repeat- 
ed, the greater will be the difficulty, in general, of effecting a cure; 
and when the mind has once become obviously affecied or impaired 
by its attacks, all hopes of a cure may be abandoned. Experience, 
too, has shown that those epilepsies which commence soon after birth, 
or during early infancy, rarely, if ever, yield to remedial treatment. 
From the period of dentition to that of puberty, is the most favourable 
age for the cure of this affection. Hippocrates observes, that those 
who are attacked with epilepsy after the twenty-fifth year of age, will 
continue to have it as long as they live^-an observation which, though 
very generally correct, is not confirmed by the experience of subse- 
quent practitioners.! When the disease is the consequence of excessive 
venereal indulgence or masturbation, it may sometimes be removed, 
provided the mental powers have not as yet suffered considerably 
from its repeated attacks, or from the influence of its cause. The 
epileptic paroxysms, which sometimes occur in the exanthematous 
diseases, are seldom followed by serious consequences, and very rarely 
occur afterwards. 

When the premonitory symptoms consist of some affections in the 
head, it may be regarded as more unfavourable than if they manifest 
themselves in remote parts of the body, particularly in the extremities. 
Richter observes, that a long continuance of the sleep, and subsequent 
mental stupor and confusion after the subsidence of the paroxysm, are 
very unfavourable signs. 

Epilepsy from moral causes, particularly from violent anger or grief, 

* Dr. Dewees, in his work on the " Practice of Physic," has inadvertently 
expressed contradictory sentiments in relation to the curableness of this disease. 
Under the head of treatment, he asks, " What plan of treatment has ever succeeded 
in curing epilepsy'? Has epilepsy ever been cured?" Under the head of diag- 
nosis, however, he says, " When the disease is symptomatic, it is occasionally 
curable;" again, "those attacked between the fourth and tenth year may be cured 
by proper treatment." Most assuredly this latter sentiment accords with the ex- 
perience of the ablest of the profession of all ages. However appalling and really 
intractable this disease may in general be, perfect cures are by no means so un- 
common as the doctor's interrogatories might lead one to suspect. I have known 
at least five distinctly marked cases cured under my own observation, two of which 
were of more than two years standing, and one above six years. 

| He says, moreover, that when epilepsy commences before the fourteenth year, 
and is not connected with an hereditary predisposition to the disease, it frequently 
terminates spontaneously in after-life. — Aphor. xv, s. 7. — Aphor. vii, s. 5. — Aphor. 
xlv, s. 2. 



58 EPILEPSY. 

is said to be very rarely cured. (Jahn, Klinik. d. Chronisch. Krankh., 
bd. i, p. 276.) It is also asserted, that those cases which come on at 
night during sleep, are in general more intractable than such as occur 
during the day, and are preceded by premonitory symptoms (Kichter.) 
It has been affirmed by men of great experience, that^epilepsy occa- 
sionally ceases spontaneously on a change of climate. 

Treatment.— There is, perhaps, no disease in which medical treat- 
ment is so frequently purely empirical as the one now under consi- 
deration. The causes are so multifarious, and generally so obscure, 
or so wholly beyond our cognizance, that we are seldom enabled to 
prescribe with any degree of reliance upon general and rational the- 
rapeutic principles. In this state of perplexity and uncertainty, we 
have often no other alternative left us, than to administer remedies, 
without being able to give any other reason for their use than that 
they have been occasionally successfully employed. True as this ob- 
servation unquestionably is, we have nevertheless, in some instances 
at least, sufficient lights in the symptoms and causes to lead us to a 
consistent and rational plan of treatment. When called to a case of 
epilepsy, the first object of the practitioner should be to inquire into 
the nature of its exciting cause, its duration, the time and manner of 
the first attack, the general constitutional habit of the patient, his age, 
previous or concomitant diseases, his habitual temper and disposition 
of mind, his manner of living, his probable hereditary predisposition, 
in short, into every thing which can throw light on the particular 
character of the disease, and on the constitutional or acquired habits 
of the patient. 

Authors assert, that when the premonitory sensation, termed aura, 
commences in one of the lower extremities, the epileptic paroxysm 
may sometimes be effectually prevented, when it is approaching, by 
compressing the limb firmly with a tourniquet or ligature above the 
part at which the aura may have reached. Dr. Cullen observes, 
" that a ligature upon the limb above the part from which the aura 
arises, should always in those cases be applied, both because the pre- 
vention of a fit breaks the habit of the disease, and because the fre- 
quent compression renders the nerves less fit to propagate the aura."t 
Dr. Cook mentions an instance from the London Medical and Phy- 
sical Journal, in which pressure made in this way prevented the 
paroxysm. Richter states, that when compression is thus made on a 
limb, above the ascending aura, the patient generally experiences great 
anxiety of feeling in the praeeordia, with extremely painful twiches 
in the compressed limb, accompanied sometimes with a sensation as 
if a heavy stone were thrown upon it. Brechstedt and Michaelis 
assert that the application of the tourniquet upon a leg has been known 

* Lentin, in Hufeland's Journal, bd. xiv, s. hi, p. 17. 

t [The late Mr. Loper, prompter of the Chestnut Street Theatre, could always 
prevent a monthly paroxysm of epilepsy by applying a tourniquet to his left thigh 
the instant he felt the aurA creeping up from his left ring toe. On one occasion 
however, he was prevented by the exigencies of his calling from applying this 
prophylactic, and the attack which followed proved fatal. — Mc] 



EPILEPSY. 59 

to put a speedy stop to the epileptic paroxysm after it had actually 
supervened.* In persons of robust and plethoric habits, prompt and 
efficient bleeding on the occurrence of the premonitory symptoms, 
has been known to keep off the epileptic attack. Active purgatives 
have also been recommended with the view of obviating or palliating 
the impending paroxysm, where the premonitory stage is protracted; 
but their tendency in this respect deserves little or no attention. 
Richter and other of the earlier German writers speak favourably of 
the employment of emetics with this intention. They cannot, how- 
ever, be used without considerable risk in cases attended with strong 
congestion in the vessels of the head. Richter states that they are 
only adapted to those cases which continue to recur from habit, after 
the original exciting cause has ceased to act. It even appears from 
the observations of this writer, that a radical cure may be effected in 
this way. He states that he cured a woman of this disease, by fre- 
quently suspending the paroxysms by the administration of emetics a 
short time before the expected occurrence of the epileptic attack.t It 
must be observed, however, that many highly respectable authorities 
might be adduced against the use of emetics in this affection ; and as 
a general rule, they are indeed to be regarded as of very doubtful 
propriety. Jahn, in his excellent work on chronic diseases, says that 
a draught of cold water will occasionally do more towards keeping 
off an impending attack of epilepsy than any other means; and Dr. 
Busmann has published some cases tending to confirm this observa- 
tion.:}; Some fifteen years ago, while practising in Lancaster, I knew 
an old epileptic patient who could generally keep off the paroxysm 
for some months by taking a large draught of cold water as soon as 
the premonitory symptoms came on. Without this precaution he 
seldom escaped having one or two fits a week. 

In the epileptic paroxysm, our principal object should be to dimi- 
nish the preternatural congestion of the cerebral vessels. The imme- 
diate danger of an epileptic fit arises chiefly from this condition of the 
cephalic circulation ; for when death occurs during the paroxysm of 
this disease, it is almost invariably by apoplexy, from vascular tume- 
scence, or sanguineous extravasation. When the patient is plethoric, 
and the signs of inordinate sanguineous congestion in the head are 
considerable, it will be prudent to abstract blood, and to remove every 
thing that may compress the veins of the neck, or impede the free return 
of blood from the brain to the heart. It is very doubtful, however, 
whether any treatment, during the epileptic paroxysm, can materially 
mitigate its violence, or shorten its duration. It is almost exclusively 
with the view of protecting the brain, that remedial measures can be 
resorted to during the fit with a prospect of advantage. 

The most important part of the treatment of epilepsy, however, is 

* De artum ligaturis ad nonnullos morbos interaos. Michaelis— in Medizin. 
Pract. Bibliothek., bd. i, st. iii, p. 397 — as quoted by Richter. 
f Specielle Therapie, bd. vii, p. 630. 
X Hufeland's Journal, bd. x, st. ii, p. 133. 



60 EPILEPSY. 

that which is proper during the intervals of the paroxysms, for the 
purpose of effecting a permanent removal of the disease. 

I have already adverted to the importance of attending to the 
nature of the exciting cause in instituting a course of treatment lor 
its radical cure. If our inquiries in this respect are successlul, ^ wm 
not be difficult to lay down an appropriate plan of treatment. 1 hus, 
if, on a careful examination, it appears that the bowels are in a loaded 
and irritated state, and particularly if signs of intestinal irritation 
existed, in a very obvious manner, previous to the occurrence of the 
disease, it would be exceedingly unwise to neglect the state of the 
bowels, and to resort at once to some one of the numberless remedies 
usually recommended in the disease. Epilepsy from this cause is 
principally confined to infancy and childhood. It is in this variety of 
the disease that emetics have most frequently been found useful. 
When symptoms of gastric irritation — such as nausea, flatulency, 
disturbed sleep, and other manifestations of indigestion are present, 
in children affected with this disease, a course of emetics have been 
used with decided success. (Richter.) In a child which had been 
affected with occasional epileptic paroxysms for upwards of eighteen 
months, I succeeded in removing the disease entirely by a course of 
emetics, (ipecac.) administered every third day.* Dr. Clark recom- 
mends a solution of sulphate of zinc, in an aqueous infusion of ipe- 
cacuanha, to be given every six, eight, or ten days. 

Absorbents have also been recommended in the epilepsies of in- 
fants, attended with gastric disturbance ; and when used in conjunc- 
tion with mild tonics, and an occasional aperient, they are sometimes 
beneficial, particularly where there is much acidity in the primse viae.t 

Richter observes, that we have reason to presume that the remote 
cause of the disease is seated in the stomach when vomiting occurs 
at the close of the paroxysm. He mentions also a peculiar tremulous 
motion of the under lip, as a sign of gastric irritation, from vitiated 
secretions or other offensive matters. Van Swieten relates a case of 
epilepsy, the fits of which were always preceded by a remarkable 
tremor of the under lip. The case was treated by emetics and pur- 
gatives, and thereby permanently removed.^ If symptoms of intesti- 
nal worms are present, anthelmintic remedies are decidedly indicated. 
Small and repeated doses of calomel, with an occasional dose of castor 
oil in union with a small portion of spirits of turpentine ; or infusion 
of spigelia, followed with a full dose of calomel and jalap, will some- 
times answer in such cases. 

* This case came on after an attack of ague, which was cured by Fowler's 
solution. 

f The famous powder of Margrave, which is still a good deal used by some 
of the German practitioners in infantile epilepsy, owes whatever powers it pos- 
sesses to its absorbent, tonic, and aperient virtues. It is composed of one ounce 
of powdered mistletoe, the same quantity of sugar, and half an ounce of the car- 
bonate of magnesia. The dose is a teaspoonful two or three times dailv for a 
child under five years old. — Richters Spec. Therap.. bd. vii p. 645 

% Comment., t. iii, p. 439. 



EPILEPSY. 61 

In verminous epilepsy, full doses of powdered valerian with the 
elutriated oxyde of tin, have been successfully used. From one to two 
drachms of the former, with thirty to forty grains of the latter, may 
be taken three times daily. 

Should it appear that the disease arose, in the first instance, from 
sudden suppression of the perspiration, a course of diaphoretics, and 
whatever else may have a tendency to keep up a regular action of 
the cutaneous exhalents, should be resorted to. Frictions with dry 
flannel ; the occasional use of the warm bath, rendered more stimu- 
lating by the addition of common salt; flannel worn next the skin; 
active exercise when the weather is dry ; the internal use of diapho- 
retic remedies — such as the pulvis antimonialis; camphor in union 
with tartar emetic; the tincture of gnaiacum ; and sulphur, are ap- 
propriate and occasionally beneficial remedies in such cases. 

When epilepsy arises from the repulsion of cutaneous eruptions, or 
the drying up of old ulcers, the manifest indication is to restore these 
affections ; or, if this cannot be done, to establish others artificially in 
their stead. For this purpose we may employ issues, setons, blisters, 
and particularly frictions with tartar emetic ointment, together with 
diaphoretics, warm bathing, and stimulating frictions. Richter says, 
that in such cases, vomits are occasionally very useful ; he also speaks 
favourably of the use of musk and camphor in epilepsy arising from 
causes of this kind. Prichard recommends mercury, given to the 
extent of producing ptyalism, in this variety of the disease. One of 
his patients was perfectly cured by a copious salivation. 

In those cases which occur in young females, in consequence of an 
unsuccessful or imperfect menstrual effort, the indications are, to re- 
move the preternatural determination to the head, and to establish or 
restore the natural determination to the uterine system, and thereby 
promote the regular performance of the menstrual function. This 
variety of the disease occurs chiefly in young females of sanguine 
temperament ; and bleeding, therefore, can seldom be dispensed with. 
Indeed, in all cases of this kind I have met with, bleeding was deci- 
dedly indicated by the condition of the pulse, the occasionally flushed 
countenance, and sense of fullness in the head. Dr. Prichard, speak- 
ing of this variety of the diseasej-which he calls uterine, observes — 
"The immediate effects of blood-letting are generally relief of the 
pain and oppression of the head, and a subsidence of the carotid and 
temporal pulsations. Sometimes the use of the lancet is speedily 
followed by a restoration of the catamenia." He advises that the 
blood be taken while the patient is sitting up, and that it be suffered. 
to flow until syncope begins to come on. In addition to bleeding in 
cases of this kind, the warm semicupium is a valuable remedy.* 
We may also employ frictions about the loins, back, and pubic region, 
and stimulating enemata, with advantage. Prichard recommends 
clysters composed of spirits of turpentine and castor oil, in such cases. 
An ounce of each may be occasionally thrown into the rectum. After 

* The bath, says Prichard, should be about the temperature of 95° or 98° of 
Fahrenheit's scale. — Treatise on Diseases of the Nervous System. Lond. ; 1822. 



62 EPILEPSY. 

the plethoric or phlogistic state of the system has been reduced by 
the foregoing measures, it will be proper to resort to emmenagogue 
remedies, if the menstrual evacuation has not already been restored. 
The following pill may be employed for this purpose.* According 
to the experience of Dr. Prichard, the best emmenagogue we possess 
in uterine epilepsy is the oil of turpentine. It should be given in 
doses of from a half to two drachms once or twice daily. I used the 
turpentine in a case, about eighteen months ago, with complete 
success. Setons in the nape of the neck, or on the arms, or on the 
sacrum, have also been recommended. This variety of epilepsy is 
almost invariably suspended by pregnancy. 

In epilepsy from onanism, besides the proper moral influences, 
Richter strongly recommends the use of camphor in regular and full 
doses. That this article possesses the power of lessening the venereal 
propensity I am fully persuaded, and its general influence, independ- 
ent of this particular effect, renders it a suitable remedy in cases of 
this kind. Patients affected with epilepsy from this cause, should 
sleep on a hard matress, rise early, take exercise in the open air, 
and use a mild and unirritating diet. The tepid shower-bath, and 
laborious occupations, will sometimes assist materially in removing 
the habit upon which the disease depends, and without the discon- 
tinuance of this habit, nothing useful can be expected from remedial 
treatment t 

Epilepsy from local injuries of the head has been cured by surgical 
operations. Boerhaave, Thenier, Stalpart, and Van der Weil, relate 
instances in which trepanning succeeded in removing the disease. 
Tissot also mentions several instances of this kind. Dr. Massie gives 
an account of a case of epilepsy which was produced by a blow on 
the head, and consequent depression of a portion of the cranial bones. 
After the disease had continued about four years, the patient was 
trepanned, and a spicula of the bone removed, after which the pa- 
roxysms returned no more.J 

Instances have also occurred in which epilepsy was cured by sur- 
gical operations on other parts of the body than the head. Portal 
relates a case where the paroxysms always commenced with violent 
pain in the index finger. This patient was cured by dividing the 
radial nerves.§ The disease has sometimes terminated spontaneously 
after the removal of spiculse of bones, balls, tumours, or other foreign 
bodies pressing upon particular nerves. || Dr. Dudley, of Lexington, 
succeeded in curing a case of epilepsy by removing a spicula of bone 

* R.— Extract, sabinse ^ii. 
G. aloes lace. Qi. 

Sulphat. ferri gr. x.— M. Fiant pil. No. 40. Take one every six hours, 
[t In this class of cases, the application of solid nitrate of silver to the prostatic 
portion of the urethra is especially serviceable. — Mc] 
% Philadelphia Med. and Phys. Journ., 1809, No. 35. 
§ Cours d'Anatomie Medicale, t. iv, pp. 247, 272. 

|| Memoires sur la Nature et le Traitement de Plusieurs Maladies Par Ant 
Portal, vol. xi. p. 229. (Richter.) 



EPILEPSY. 63 

which had penetrated the substance of the brain to a considerable 
distance. Dr. Rogers, of New York, succeeded in a case by a similar 
operation; and an instance is related by Dr. Guild, of Alabama, which 
was cured by the operation of trephining.* This case is an extremely 
interesting one, and deserves to be consulted as a remarkable instance 
of successful trephining for this disease.! 

Where we can ascertain the remote cause of the disease, we should 
always found the plan of treatment on the general indications which 
such a knowledge is capable of affording. In the majority of in- 
stances, however, we are wholly left in the dark with regard to this 
point, and very frequently indeed, all our efforts to cure the disease, 
under the guidance of what we may deem the most unequivocal 
curative indications, are unsuccessful. In this case we are obliged, 
if we wish to pursue our endeavours to effect a cure, to resort to one, 
or many, by turns, of that long list of remedies which, according to 
the reports of eminent practitioners, or our own experience, have oc- 
casionally succeeded in removing the disease, without our being able 
to give any other satisfactory reason why they are resorted to. The 
following are the most celebrated of these anti-epileptic remedies. 

Valerian. — This is one of the most ancient remedies employed in 

[* I applied the trephine in one case, over the seat of an old injury of the skull, 
and extracted fragments of the internal table which had been driven inwards 
through the dura mater, so as to penetrate the cerebral substance. But a great 
deal of grisly induration existed around and below these fragments, so that, al- 
though the patient recovered from the operation, subsequent paroxyms of epi- 
lepsy were not prevented. He was relieved in some measure, however, from 
the violent spasms of the opposite side, with which he had been occasionally 
afflicted for several months before. From the experience of surgeons within my 
course of observation I have not been able to form a favourable opinion of the 
operation of trephining, in cases of epilepsy following injuries. 

The operation of securing the common carotid artery, has been recommended 
on the principle of diminishing the flow of blood through the brain in severe 
cases of epilepsy. Dr. McGill, of Hagerstown, is said to have performed this ope- 
ration repeatedly, and in one case upon both the common carotids at two succes- 
sive operations on the same subject. Whether his success was permanent or 
merely temporary, I have had no opportunity of ascertaining. In a case of 
violent epilepsy connected with the protrusion of a pulsating vascular tumour, 
(aneurism by anastomosis) through the parietal bone, I took up the common 
carotid. The result was that the tumour shriveled away, and the epileptic pa- 
roxysms disappeared for about six months, when they reappeared with dimi- 
nished violence. 

The division of the sensitive nerves, which supply painful spots on the scalp, 
sometimes affords relief. I cured a young engineer of a bad epilepsy which had 
followed a blow on the upper region of the right side of the os frontis, received 
in the famous Bristol riot some three years before. A hard cicatrix remained 
over the principal branch of the frontal nerve, and pressure upon it would at any 
time excite a paroxysm. I cut out the cicatrix, and a portion of the nerve with it, 
and the disease never recurrred. — Mc] 

t American Journal of Medical Science. October, 1829. 



64 EPILEPSY. 

this disease. Aretaeus and Dioscorides recommend it as a valuable 
medicine in this affection; and it is favourably mentioned by many 
of the most celebrated of modern writers.* It should be given m as 
large doses as the stomach will bear. From one to two drachms may 
be taken three times daily. This article is said to be most apt to do 
good in epilepsies from verminous irritation, suppressed catamema, 
terror, and repelled cutaneous eruptions. Quarin used it with success 
in epilepsy of infants. (Richter.)t Biett generally employs the oil 
of valerian in this affection in doses of from 40 to 50 drops three 
times daily. (Casper. Charakter. d. Fanz. Med., p. 192.) 

The mistletoe also' is a very old remedy in epilepsy ; and if we are 
to place any reliance on the testimony of Boerhaave, De Haen, Van 
Swieten, Hufeland, Stark, and Richter, we cannot doubt of its having 
proved effectual in removing this affection. Cullen admits that in 
large doses it may perhaps be useful ; but he thinks it probable, and 
with justice, that the reputation it once had arose in a great measure 
from its having been an object of superstition, and thus calling in the 
powerful aid of the imagination to whatever powers it may really 
possess of itself. Frazer, in a small work published on the powers 
of this article, asserts that he cured nine cases out of eleven with this 
medicine. He gave it in powder, in doses of from two scruples to 
two drachms, twice daily in a draught of camphorated emulsion. 
(Cook.) We have, moreover, the testimony of Fothergill and Dr. 
Willan, in favour of this article as a remedy in epilepsy. Of late 
years, however, it has fallen into total neglect. I knew an empiric 
who succeeded in curing several old cases with this article. 

The animal oil of Dippel% also was formerly a good deal em- 

* Hoffman, De Haen, Burserius, Haller, Murray, Selle, Tissot, Thilenius, Vogel, 
Hanneman, Horn, Quarin, and others, recommend it as a valuable remedy in epi- 
lepsy. On the other hand, Cullen, Home, Heberden, and Woodville, regard it as 
of but little value in this disease. 

t The famous anti-epileplic powder of Ragolai contains a large proportion of vale- 
rian. According to Knopfs analysis, this nostrum is composed of one drachm of 
valerian, one scruple of orange leaves, two grains of muriate of ammonia, and a 
few drops of cajeput oil. Jahn thinks that it contains a portion of the powdered 
root of the convallaria majalis ; and some assert that it consists of a mixture of 
valerian, agaric, and an ethereal oil. This remedy, according to the testimony 
of Richter and others, has cured obstinate and even inveterate' cases of epilepsy. 
Richter succeeded in curing a case of four years' standing, by a powder composed 
of one drachm of valerian, with three drops of cajeput oil, taken four times daily 
for six weeks. (Therap. Speciel., vol. ii, p. 672.) In this city the following com- 
position has been used with complete success in some instances, and frequently 
with the effect of postponing the paroxysm for many months. 

R. — Pulv. zingiberis. 

fol. salvias. 

sem. sinapi, aa 3 i.— Dose, a teaspoonful three times daily. I have 

myself employed this powder with advantage in a few cases, though never with 
complete success. 

$ Dippel, Disquisitio de Vitae Animalis Morbis, p. 89 



EPILEPSY. 65 

ployed in the treatment of this disease; and we have the testimony 
of Hoffman, Cullen, Bang,* Kortrum, Quarin, Werlhof, Thouvenel, 
Van Hoven, and others in its favour. It is given in doses of from 20 
to 50 drops three times daily. It is said by Richter to be most useful 
in epilepsies originating from metastatic gout, rheumatism, and from 
repelled cutaneous eruptions. 

The oil of turpentine has at present no inconsiderable reputation 
as a remedy in this disease. I have already mentioned its usefulness 
in epilepsy from menstrual disorder, on the authority of Dr. Prichard. 
It has also been successfully used in other varieties, particularly in 
cases depending on intestinal irritation from worms and other offen- 
sive matters. Dr. Latham cured several cases of epilepsy with this 
remedy. Dr. Young has given an account of two cases which yielded 
under the use of this remedy ;t and Dr. E. Percival relates three 
instances of its successful employment.^ Dr. W. Money also testifies 
to the usefulness of this article in epilepsy; and Dr. Prichard assures 
us that of all other remedies which he has tried in this disease, he 
has found none so frequently useful as the oil of turpentine. (Loc. 
cit.) Biett is said to employ this oil frequently for the cure of epilepsy 
in the Hospital St. Louis. This article should be given in doses vary- 
ing from half to two drachms three times daily. Fresh milk is per- 
haps the best vehicle for administering it. 

The root of the pseony was anciently highly esteemed for its powers 
in this disease. It was a favourite remedy with Stark ; and it is parti- 
cularly recommended byHufeland, Jahn,§and Thom. Hufeland says, 
it is especially useful in the epileptic affections of children. The 
powder is given in doses of half a drachm three times daily, or an 
infusion of one ounce of the root to eight ounces of water given in 
tablespoonful doses every two hours. 

tftgaricus mnscarius was first employed in this disease by Bern- 
hard. Wistling and Gruner afterwards published statements illustra- 
tive of its powers in this affection. (Richter.) It is said to be most 
useful in cases originating from repelled cutaneous eruptions. The 
dose is from a scruple to a drachm three times daily. 

Artemisia vulgaris, or mugwort, has been lately much commended 
for its virtues in this disease by several eminent German practitioners. 
About eight years ago, Dr. Burdach, an eminent physician and writer, 
published an account of the successful treatment of several cases of 
epilepsy by this root ; and in a recent number of Hufeland's Journal, 
he has adduced further evidence of its usefulness in this disease. It 
is a remarkable circumstance, he says, that in nearly every case in 
which this article proved successful, an evident amendment of the 
disease took place from the first dose. It appears further from the 
experience of this physician, that in cases of epilepsy occurring in 
mule subjects about the age of puberty, this remedy very seldom does 

* Acta Societ. Med. Hav. vol. i, p. 500. 
f Transactions of the College of Physicians, Loud., vol. v. 
% Edinb. Med. and Surg. Journ., vol. ix, p. 271. 
k Klinik. d. Chron. Krankh., bd. i, p. 282. 
VOL. II. — 6 



66 EPILEPSY. 

any good. In young females about the same age, « its beneficial 
effecfs are often prompt and decisive." He occasionally lound it 
very speedily successful in apparently very obstinate cases, while in 
others, seemingly quite similar, it was wholly inefficient. An inte- 
resting instance of the successful employment of this remedy is related 
by Dr. Wagner, in Hufeland's Journal (vol. for 1824). And m the 
12th Annual Report of the Berlin Polyclinic Institute, there is another 
case related which yielded under the use of the artemisia. It is usually 
given according to the following formula.* This is not a new remedy. 
Ettmuller mentions its use in epilepsy ; and Zwinger, speaking of 
this plant, says, mire in epilepsia valet. The internal ligneous part 
of the root is inert. The cortical portion alone is said to possess 
medicinal powers. The artemisia is indigenous to this country, par- 
ticularly to Pennsylvania.! 

Of the narcotics, belladonna,} opium,§ camphor,|| and stramonium,! 
have been most recommended in this affection. Some of the anti- 
spasmodics also have been employed with benefit in epilepsy. Among 
these, musk, castor, assafcetid a, are generally supposed to be the most 

* K. — Pulv. rad. artem. vulg. £ss. 

Pulv. sacch. albi ^i. — M. Of this, about a teaspoonful is to be taken four 
times daily, the dose being gradually increased. 

f Besides the foregoing remedies, a great many others of a similar character 
have been recommended in this affection. Veratrum Alburn (Stark, Schulze, 
Greding). The roots of the white lily (Hufeland's Journ., b. xxxi, p. 30), Phe- 
landrivm aqvaticum ; faba St. Ignatii; the fresh juice of white onions (Hufeland's 
Annalen) ; Radix meu (Jahn) ; the juice of unripe grapes (L. Frank, Loebstein- 
Loebel) ; sedum acre (Zachorn, Hufeland's Journ., bd. xl, p. 19); folia aurantiorum 
(Van Swieten, De Haen, Stoerk, Werlhof, Stark, Hufeland, Thilenius). The car- 
bonate of potash, in large doses, is recommended in recent cases. (Hufeland's 
Journ., bd. viii, p. 170.) 

t Stoll (Ratio Medend., vol. iii, p. 406), Hufeland (Journal d. Prack. Heilk., 
bd. ix). Greding (Vermischte Shriften), and Jahn (Klinik. d. Chron. Krank., b. i, 
p. 282), speak favourably of this narcotic as a remedy in epilepsy. Richter says, 
it should never be given to children— or in cases attended with habitual congestion 
of the cerebral vessels. 

§ Tralles (Usu Opii Salubris et Noxius, &c, p. 16). Fothergill (Med. Observ. 
and Inquir., vol. vi, p. 80), asserts that opium may be very beneficially used in 
cases attended with a weak, irritable, and nervous habit of body : and in cases that 
arise from violent pain or mental excitement. Dr. Huxy relates an instance of the 
successful employment of opium in epilepsy; and Dr. Darwin tells us that in two 
cases in which the fit always occurred at night during sleep, a grain of opium given 
at bed-time removed the disease completely. 

|| Richter says, that camphor is sometimes particularly useful in cases that depend 
on onanism, or on the repulsion of chronic cutaneous eruptions. (Loc cit b vii 
p. 682.) "' ' ' 

IT This article is much praised as a remedy for epilepsy by some of the Swedish 
writers. Ohdelius speaks favourably of it; and Greding cured a few cases with 
its use. Hufeland asserts, that he has used the tinct. sem. stramon. with decided 
benefit in this disease. (Journal, bd. ix ; st. 3.) 



EPILEPSY. 67 

useful. Very commonly, however, no advantage whatever is to be 
derived from remedies of this kind ; and they are often manifestly in- 
jurious, by their tendency of increasing preternatural determination 
to the head. 

Of late years, phosphorus has been strongly recommended by some 
as a remedy in this affection. I gave it in one case about two years 
ago, and although it did not perform a cure, it suspended the pa- 
roxysm above three months beyond its usual period of recurrence. 
Four grains may be dissolved in half an ounce of sulphuric ether. 
Of this, from eight to ten drops should be given three times daily 
in some mucilaginous fluid.* This article cannot, however, be em- 
ployed with propriety in cases attended with general plethora, or 
habitual congestions in the cephalic vessels. Where symptomatic 
epilepsy is connected with torpor of the vascular and nervous systems, 
or general debility and relaxation, advantage may be expected from 
it. Loebstein-Loebel, Van Hoven, and Horn, relate instances of its 
successful employment. 

The oxyde of zinc is generally regarded as one of our most effi- 
cient remedies in epilepsy ; and from the testimony extant in relation 
to its powers, as well as from facts which have come under my own 
notice, I am inclined to regard it as a medicine of considerable value 
in this affection. t This article is generally given in much too small 
doses to do any good in epilepsy. It may be commenced with in 
doses of three grains thrice daily, and gradually increased to the 
amount of forty or fifty grains a day. Dr. Guthrie cured a case in 
which the paroxysms returned three or four times daily, with this 
article given to the extent of eight grains on the first day, and gra- 
dually increased to forty grains in twenty-four hours. (Duncan's 
iftnnals of Med., vol. iv, p. 473.) It is generally given by itself; but 
it would seem that its powers may at times be enhanced by combin- 
ing it with bitter and laxative remedies. Lentin (Hufeland's Journ.. 
bd. xiv, st. iii, p. 13), cured an inveterate case with a powder com- 
posed of fifteen grains of magnesia, from two to eight grains of oxyde 
of zinc, two grains of the extract of quassia, and two drops of cajeput 
oil, twice daily. Stroubel (Hufeland's Journ., bd. 52, st. i, p. 40), 

* In Horn's Archives of Medicine (bd. X, lift. ii ; p. 270), the following formula 
is given for the administration of this article: 

R. — 01. tereb. ,^ss; 01. olivar. giii ; Phosphor, gr. ii; put them into a half ounce 
phial, and digest it in warm water until the phosphorus is dissolved; then add mu- 
cilage of gum Arabic giv; syrup of cinnamon gss. — M. Dose ; a dessertspoonful 
every 3 or 4 hours. (Richter, loc. cit.) 

t This remedy has been used with success by Bell and Percival, (Edinb. Med. 
Comment., v. i, p. 229, and v. ii, p. 316;) Bcirics, Home. (Clinical Experiments, 
p. 223;) Ranoe, (Acta Societ. Med. Hafn., vol. i, pp. 451, 457 ;) Mdzchcr, (Adversar. 
Med., v. ii,p. 98 ;) Osiander, (Denkwairdigk., bd. ii. p. 188 :) Hirschel, Richter, (Med. 
Chir. Nebenst, pp. 161, 190;) Shearman, (Loud. Med. and Phys. Repos., Sept.. 
1822 :) P. Frank, (Prax. Med. Univ. Praec, ii, torn, i, p. 409 ;) Dr. Haygarth. Dr. 
White, (Cook on Nervous Diseases, p. 398 ;) Van Hoccn, (Handbuch, bd. ii, p. 
131.) 



68 EPILEPSY. 

used this metallic preparation, in union with mistletoe, with com- 
plete success, in a case attended with much nervous irritability. 

The sulphate of zinc has also been occasionally used with suc- 
cess in this affection. It is favourably mentioned, in this respect, by 
Lettsom, Weikart, Collen, Ideler. (flu/eland's Jottrn., bd. iv, p. 1 14.) 

Cuprum ammoniucum. This was the favourite remedy in epi- 
lepsy with Cullen. I have given it in ten or twelve cases, one of 
which only derived any decided benefit from its use. This article 
is indeed a very old remedy in this affection. Areta3iis mentions it 
as a valuable anti-epileptic. Richter observes, that the cuprum 
ummoniacum is only calculated to do good in cases attended with 
a torpid, unirritable, and phlegmatic constitution, and a healthy state 
of the digestive functions, and when it is continued from habit.* 
According to Stark, it is especially beneficial in cases depending on 
verminous irritation, or on repelled herpetic eruptions. Haase, an 
eminent German writer, asserts that it is much better adapted to the 
cure of epilepsy in adults than in children ; and he agrees with 
Richter in regarding unirritable and phlegmatic subjects as most apt 
to derive benefit from its use. The dose at first is from a quarter to 
half a grain, and gradually increased to one or one and a half grains 
three times daily, or until it creates considerable nausea and gastric 
disturbance. Dippel refers to a preparation of copper, consisting of 
a union of this metal with potash, ammonia, and oil of turpentine, 
which, he avers, has been used with the most decided benefit in 
epilepsy. (Richter, Specielle Therapie, bd. vii, p. 701.) The mode 
of preparing this mixture is given by Durr (in Hufeland's Journal, 
bd. xxviii, st. iv, p. 117). Richter says, that when given in union 
with valerian, its effects are generally more beneficial. 

The nitrate of silver possesses at present more reputation as a 
remedy in epilepsy than perhaps any other remedial article. It 
would be an easy matter to collect a very considerable number of 
instances of its successful employment in this disease.t From the 

* Numerous authorities may be quoted in favour of the anti-epileptic powers 
of this preparation. The most celebrated are, Burserius, (Instit. Pract, vol. hi, 
p. 11, $ 289;) Loebstein-Loebel, (Wesen. u. Heilung d. Epilepsie, p. 234:) Duncan, 
Harks, (Journ. d. Auslaend Med. Liter., bd. iv, st. 2 ;) Bland, (Medical Commen- 
taries, vol. vii, p. 300 ;) Greding, (Vermischte Schriften, bd. i, p. 103 ;.) Michachs, 
(Med. Pr. Bibl., 1785, b. i, st. 3;) Stark, (Handbuch Z. Erkennt, &c.;) /. Frank, 
(Praxeos Med. Univ. Praec, p. ii, vol. i, p. 412;) Haase, (Chron. Krankh., bd. ii, 
s. 103;) Thilenius, (Med. u. Chir. Bemerk, bd. i, p. 103;) Bally, (Duncan, Medi- 
cal Annals, vol. i, Lust., p. 337.) 

f It has been used with success, in well marked and often long standing cases 
of epilepsy, by Sims, (Mem. of the Soc. of Lond., vol. vi, p. 397 ;) Cappe, (Dun- 
can's Annals, for 1798, p. 56;) Bostock, Hull, Heberden, (Commentaries;) Sau- 
chier, (Annal. de la Societ. de Med. de Montpell., t. vii, pp. 369, 384;) Valentin, 
(ibid., t. viii, p. 182;) Heim, Nord, (Med. Nationalzeit., 1798) Born (Hufe- 
land's Journal, bd. xlv, st. i, p. 93;) Shaeffer, (ibid., bd. xlviii, p. 43 ;) Pitschaft, 
(ibid., bd. h, st. 3, p. 54;) Loebstein-Loebel, (Wesen u. Heil. d. Epilepsie p 
243;) Portal, Fouquier, (Diet, des Sciences Med., t. xxxvii, p. 120;) Harrison 



EPILEPSY. 69 

various and highly respectable testimonies we have in relation to its 
powers, it is, without doubt, entitled to much attention as a remedy- 
in this affection. In order to obtain its beneficial effects as an anti- 
epileptic, this preparation should be given in as large doses as the 
stomach will bear. Dr. Powell observes, that the nitrate of silver 
may be taken into the stomach in much larger quantities without 
inconvenience in the form of pills than in solution. We may com- 
mence with one grain, and gradually increase the dose to three or 
four grains or more three times daily. Richter states, that this arti- 
cle seldom does any good unless the digestive organs are in a healthy 
and vigorous condition ; and Dr. Harrison considers it particularly 
adapted to those cases which are connected with a morbid irritability 
of the nervous system.* I have given it in a number of cases— in 
one case only, however, did it prove permanently successful. Kru- 
iger employed this article with success according to the following 
formula.! The nitrate of silver will sometimes manifest no bene- 
ficial effects until its use has been continued for many months. Toel 
(Horn's Archives, 1824), relates a case in which the paroxysms re- 
curred regularly every month, at night during sleep, which yielded 
at last to this remedy after it had been regularly taken for more than 
a year and a half. It is a common practice to discontinue the use of 
this and other similar remedies, if no perceptible advantage is derived 
from it in the course of six or eight weeks. This, I am persuaded, is 
not unfrequently the source of defeat in our attempts to subdue this 
complaint. I once succeeded in curing a case of seven years' con- 
tinuance, by persisting with the same remedy for nine months. 

Tin. — This article has recently been strongly recommended in 
the cure of epilepsy. Dr. Shearman states, that in his hands the 
elutriated oxyde of tin has more frequently succeeded in curing this 
affection than any other remedy he has ever employed. He gave it 
in doses of from two scruples to one drachm, night and morning, 
for about four days. At the end of that time he ordered a purgative, 
and again gave this preparation, or not, according to its effects on the 
system.J The filings of tin, given in large doses, have been used 

Baillie, Roget, Johnson, (Cook on Nervous Diseases, p. 394 ;) Barladini, (Omo- 
dei Annal.di Medic, 1826. p. 41 ;) Jahn, (Arzneinuttell, bd. i, andKlinik. d. Chron. 
Krankh., b. i, p. 283;) Kruiger, (Archiv. f. Med. Erfahr. v. Horn, Maertz, April, 
1823;) Toel, (ibid., 1824, Nov. and Dec.;) Biett, (Caspar. Charakt. d. Franzoe- 
6ish.Med.,p. 191.) 

* [I have formed an opinion that it is especially serviceable in all those cases 
of epilepsy which are dependent upon sympathy with a morbid condition of the 
stomach ; at least it has been in such cases only that I have had any success with 
the remedy. — Mc] 

t R. — Nitrat. argenti gr. vi. 
G. opii gr. x. 
Extract, gentian ^i. 

Extract, aloes 9 i. — M. Divide into two grain pills. Take one three 
times daily, increasing the number from time to time. 

% London Medical Repository. 



70 EPILEPSY. 

with success in epilepsy from verminous irritation by Richtcr, (As- 
klepewn, 1S11, st. 67, s. 1060,) and Monro. (A Treatise on Med. 
and Pharm. Chem., vol. i, p. 2S9.) From the acknowledged an- 
thelmintic properties of this article, it is manifestly peculiarly adapted 
to cases which depend on irritation from worms. 

Lead.— The acetate of lead has been employed with entire suc- 
cess in a few instances of this disease. About sixteen years ago, I 
succeeded in curing a case with this remedy which had continued 
for upwards of seven years. The patient was a young man about 
twenty-two years old ; and the disease was excited, in the first in- 
stance, by violent terror. The paroxysms returned regularly at each 
period of full moon. I prescribed three grains of sugar of lead morn- 
ings and evenings, commencing three days before the time of full 
moon, and continuing two or three days after this period. He took 
the medicine in this manner for nine successive lunar periods; but 
the disease did not return after the fifth period from the time the 
treatment was commenced.* Dr. Rush gave this remedy in two 
grain doses with complete success in a case of this disease ;t and 
Drs. Spence and Agnew employed it, in some instances, with decided 
benefit. Saxdorph also gave it with marked advantage.:}: Quariu 
(Animadv. Pract.) and Portal condemn its use in epilepsy, as being 
inefficacious in small doses and dangerous in large ones. 

Besides the foregoing remedies, many others have been used with 
advantage. Dr. Johnson speaks favourably of the internal use of 
cantharides ; Dr. Kirkhoff has used the prussiate of iron with suc- 
cess; and Underwood has derived advantage from the use of savin. § 

Mercury, with a view to its salivant effects, was formerly much 
recommended. Burserius speaks highly of the powers of cinnabar 
in this affection. Mercurials, particularly mercurial frictions, were 
used with success by Bang, Willis, Ettmuller, J. Frank, Tissot, 
Locher, and others. 

Richter states, that the sulphuric acid sometimes produced the 
happiest effects in epilepsy. Advantage, however, is to be expected 
from its use only in cases attended with a general nervous irritability, 
and erethism of the vascular system. In such cases, from two to four 
drachms of the acid should be taken during the day. Zimmerman, 
Tissot and Hildebrand (Hufetand's Journ., bd. ix, p. 34), commend 
the anti-epileptic powers of this acid. 

Various external remedial applications also have been recom- 
mended, and occasionally used with advantage in this affection. 

* New York Medical Repository, vol. ii, No. I, 1815. 

f New York Med. Repos., vol. ii, No. I, New Series, 1813. 

% Osann. Dissertatio de Satumi Usu Medico, &c, 1809. 

$ Dr. Ferrara, of Naples, has successfully treated an obstinate case of epilepsy 
in a young gentleman, by the employment of four or five grains of ipecacuanha 
every morning, and the same dose whenever any premonitory symptoms of the 
disease appeared. Dr. Gaetano Allegretti, another Italian physician, had recourse 

to this practice in four cases, in three of which a complete cure was effected 

Am. Journ. of the Med. Sci. } vol. viii, p. 211. 



EPILEPSY. 71 

Statements have been published which go to show tha.t galvcoiisni 
may occasionally be employed with benefit. It is said to be most 
efficacious in this disease when its influence is applied some time 
before the accession of the expected paroxysm, and (when the case 
is preceded by the aura), if the positive current of the galvanic fluid 
is passed through the part where the aura commences.* According 
to the experience of Mansford, little or no advantage is gained from 
galvanism in epilepsy, unless it be applied steadily and constantly, 
and only with a weak power. He thinks that the negative point 
should be as near the brain as possible, and the positive one in some 
distinct part of the body.t 

Electricity has also been recommended for the cure of epilepsy. 
Richter states that this agent has been employed in several obstinate 
cases with great advantage. Both galvanism and electricity, how- 
ever, may do, and have done, unequivocal harm, particularly when 
applied with much force. It is only in cases attended with a torpid 
and unirritable state of the nervous system, that these powers ap- 
pear to be applicable with a prospect of benefit.:}; 

Setons and issues were at one time much used in epilepsy. Hip- 
pocrates cured a case by an issue on the crown of the head, {De 
Morb. Sacro., § vii :) and Tuipius relates a case cured in the same 
way. Mead used blisters on the back of the neck with success, {De 
Imperio So/is et Lunse, cap. xi.) Fabricius cured an obstinate case 
with a seton in the nape of the neck, {Observ. et Epistol Franc, cent. 
i, ob. 41.) The actual cautery has also been successfully applied in 
this disease. Van Swieten, Heister, Willis, De Haen, Larrey and 
others have related cases cured by this severe application. This 
remedy is mentioned by the ancients as a cure for epilepsy, particu- 
larly by Caelius Aurilianus. (Richter.) 

Larrey has published an account of some cases of epilepsy, in 
which local bleeding from the vessels of the head, and the subse- 
quent application of moxas, blisters, and other counter-irritants, 
proved completely effectual. {Revue Medicate.) 

Of lale years a good deal has been said in favour of pustulation 
with tartar emetic ointment, as a remedy in this affection. Mr. John 
Creighton has related six cases treated by frictions with this oint- 
ment, along the course of the spine, with very obvious benefit, 
though not with entire success in any one.§ More recently, Dr. 
Carter lias given an account of five cases of epilepsy, which go to 
show the usefulness of this application. || 

Music has been employed to overcome this distressing malady. 

* Walther. Uber d. Therapeutisch Indie, d. Galvanism. Richter, Specielle 
Therapie, bd. vii, p. 716. 

f Galvanism is favourably mentioned as a remedy by Martens, (Answeis. Zur. 
Therapeut. Anwend. d. Galvanismus, p. 333;) Whtilam, (Med. and Phys. Journ.. 
vol. xiv.) Burdach. 

X Electricity is particularly recommended in this disease by Albans Stoll 
Kuihn, Spengler, Wilhelm, and others. 

$ Dublin Transactions, vol. iv. || Med. Chir. Rev., vol. ix ; July 1826. 



72 CATALEPSY. 

Quarin states, bv means of this delicious power he succeeded m 
gradually weakening and finally subduing the epileptic paroxysms 
in one case. . 

Whatever mode of treatment or remedies be employed, particular 
attention should always be paid to proper regulations in relation to 
the diet, exercise and the action of the bowels.* 



Sect. TV . — Catalepsy. 

We find this very remarkable and rare disease described in the 
books under a variety of names— such as stupor vigilans, congela- 
(io, extasis,catoche, or catochus, lethargies, cams catalepsia, &c. 

Catalepsy consists in a temporary suspension of consciousness, 
sensorial power and volition — the body remaining in the precise posi- 
tion in which it was when the attack came on, without coma, mus- 
cular rigidity, or spasm ; the respiration and circulation continuing. 

The attack generally comes on without any warning of its approach. 
In some instances, however, symptoms premonitory of the cataleptic 
seizure occur, such as vertigo, cephalalgia, flushed face, a certain 
inactivity of mind and body, pain in the prsecordium, a feeling of 
heaviness or tremor in the extremities, forgetfulness, flatulent pains 
in the bowels, yawning, sensorial obtuseness, depressed spirits; and 
in some instances, a sensation similar to the aura epileptica. 

When the attack occurs, every part of the body remains in pre- 
cisely the same position in which it was at the moment of the seizure. 
If the paroxysm comes on while the person is in the act of doing 
any thing, as, for instance, drinking, the hand will be suddenly ar- 
rested with, perhaps, the glass near the lips and the mouth open. 
Even the expression of the countenance continues fixed during the 
cataleptic state, as at the moment of the attack. t The eyes are 
generally open, fixed, and slightly turned up. Sometimes they are 
spasmodically closed. One of the most remarkable circumstances 
of this afTection is the wax-like flexibility {flexibilitas cerea) of all 
the members of the body, with sufficient tonic muscular action to 
cause an extremity, or the whole of the body, to remain in the exact 
position in which it is put by another person. Thus, if during the 
cataleptic state, the arm be raised up, or in any way extended or 

* [I consider diet to be by far the most important part of medical treatment. In all 
cases attended with vascular excitement, a strict vegetable or farinaceous diet is 
absolutely necessary. I have cured several cases by this course. I took the hint 
from the case of an intimate friend, a native of Virginia, who had been afflicted 
with epileptic paroxysms from his childhood. After all other plans of treatmen 1 
had failed. Dr. Chapman directed an exclusive diet of bread and milk. He perse- 
vered in this course for many months, and has never had a paroxysm since. An 
empirical practitioner in New-England has cured hundreds of patients (whom he 
takes in to board at his own residence), by some drops of watery fluid and bread 
and water diet. — Mc] 

t Richter's Specielle Therap., bd. viii, p. 471. 



CATALEPSY. 73 

flexed, it will remain so until the paroxysm is over. To this, how- 
ever, the eyelids sometimes form an exception. When they are 
closed, they will not remain open when separated with the fingers ; 
and when open, they immediately separate again if forcibly closed, 
as soon as the force is removed. Van Swieten mentions an instance 
of the former,* and Heberden one of the latter.t In complete cata- 
lepsy, all the sensorial functions are entirely suspended, and the 
patient, on recovering, remembers nothing either of his own internal 
sensations, or of what is done about him during the paroxysm. The 
period occupied by the attack is a perfect blank in the patient's 
existence ; and if the paroxysm comes on while he is conversing, or 
in the performance of any other continuous act, he will resume the 
thread of the conversation, or even finish the half-pronounced word, 
or continue his acts, as soon as the paroxysm is over, as if no inter- 
ruption had taken place. Although voluntary motion is almost uni- 
versally suspended during the cataleptic attack, cases have occurred 
in which locomotion continued, without, however, the least con- 
sciousness in the patient of its performance. Dr. StearnsJ relates a 
case, in which, if the paroxysm came on while the patient was walk- 
ing, the same pace was unconsciously continued. Dr. Good also 
relates a similar instance, in which the involuntary walking continued 
during the attack.§ Fernelius states that he saw a cataleptic patient 
who, when pushed forwards, walked with a regular and firm step. || 
In cases less perfect, some degree of sensorial power remains, and 
the patient retains an indistinct recollection of what occurred during 
the paroxysm, on emerging out of.it. But even in cases of this kind, 
all power of voluntary motion, or of manifesting, in any manner, a 
consciousness of their situation, or a desire for any thing, is wholly 
suspended. A case is mentioned by Galen, IT in which the patient, 
one of his fellow students, lay motionless like a log, with his eyes 
open ; but he heard and remembered what occurred during the pa- 
roxysm. A remarkable case is related by M. M. Lenormand, seen 
also by Laennec and Recamier, in which there was complete immo- 
bility, rigidity of the whole body, pulse weak, expression of the 
countenance natural, and abolition of all the senses, except that of 
hearing ; the patient (a young female) heard every thing that was 
said in her presence, but was totally unable to make the least sign, 
or utter the weakest sound. In the course of the third weak, her 
hearing also failed, and her limbs became flexible, and readily as- 
sumed any position in which her attendants placed them. During the 
intervals of the attacks, she suffered much anxiety and pain in the pit 
of the stomach.** It is even stated that instances have occurred of 
catalepsy on one side only.tt 

* Comment., vol. x. p. 183. 

t Comment, on the History and Cure of Diseases, p. 291. 

X American Medical Register, vol. i, art. viii. 

$ Study of Medicine, vol. iii, p. 387. || Patholog., lib. v, cap. xi, p. 70. 

If Lib. i, Prorrhetic, p. 756. ** Rev. Medicale, Juillet, 1825. 

tt De LaMetrie, Abrege de laTheorie Chymique, &c, p. 278. (Van Swieten.) 



74 CATALEPSY. 

In some cases the respiration and pulse become so feeble as to be 
imperceptible, and the whole surface is cold and contracted, as in 
death. The flexibility of the limbs, however, remains throughout— 
a circumstance which is never observed in dead subjects. 

The duration of the cataleptic attack varies from a few minutes to 
several days. A deep inspiration generally announces the return of 
consciousness, sensation and voluntary motion. In many cases the 
paroxysm passes off suddenly, the patient recovering in an instant 
all his mental and physical powers. I saw a case lately with my 
friend Dr. Stadiger, which regularly recurred three or four times 
daily; and in which the paroxysms never continued longer than 
between one and two minutes, and always came on and passed off 
suddenly. In other instances, particularly in those of protracted 
duration, the attack goes off gradually, the power of feeling and 
motion generally returning first in the fingers, then in the arms, and 
finally in the whole of the body. In transient cases, the patient 
experiences no unpleasant feelings, or sensible diminution either of 
the mental or corporeal powers, after the paroxysm; in others, a 
feeling of weight and fullness in the head, with slight cephalalgia, 
lassitude, and some degree of sensorial obtuseness, remains for some 
time after the attack has passed off. The cataleptic attacks in some 
instances recur with more or less frequency for months or even 
years; but it has very rarely been found to assume a strictly peri- 
odical character. Sometimes several attacks may occur in the course 
of one hour.t F. Hoffman mentions the case of a woman in which 
upwards of one hundred paroxysms occurred during the period of 
forty days.J Occasionally individuals will suffer a cataleptic attack 
without ever afterwards becoming affected with it again. § 

Catalepsy sometimes succeeds, terminates in, or alternates or be- 
comes complicated with other affections. Dr. Lenormand's case, 
already referred to, was a most remarkable instance of this kind. 
The patient, a young girl, labouring under pains in the stomach and 
menstrual irregularities, passed successfully through nostalgia, fever, 
obstinate constipation, chorea, trismus, trismal catalepsy, complete 
catalepsy, chorea, a species of somnambulism, and finally hysteric 
symptoms, during the period of about eleven months. The disease 
has been known to alternate or terminate in epilepsy, anomalous 
convulsive disorders, soporose affections, and mental derangement! 
It is sometimes modified by a very peculiar morbid excitability of 
the nervous system, giving it the character of cataleptic hysteria. 
In such cases, the patient will remain in a completely cataleptic state 
for some time, and then suddenly, without a recovery of conscious- 
ness, begin either to talk incessantly, or sing, or whistle, or declaim.^ 

* Fitzpatrick, Medical Commentaries of a Society, &c, of Edin. vol. x. 
t Behreus. — Baldinger's Neu Magazin., b. ix, p. 207. 
% Medic. Ration. System., t. iv, part iii, cap. iv. 
$ Vogel. Prselectiones de Cognosc. et Curand. Morb., p. 569. 
II Hirschel Gedanken von der Starrsucht., p. 13. 

H Sauvages. Nosolog., t. ii, p. ii, p. 418. Richter, Specielle Therapie, b. viii, 
p. 477. 



CATALEPSY. 75 

Fleisch calls this modification of the disease, catalepsis loquax. 
(Richter.) Sometimes catalepsy is connected with a species of som- 
nambulism, the patient lying in what is familiarly called a trance. 

The diagnosis of catalepsy depends chiefly, if not wholly, on the 
wax-like pliability of the extremities, and their maintenance of the 
position into which they are placed by extraneous force, together 
with the entire impossibility of the least voluntary motion. (Richter.) 

The affection described in the books under the name of ecstasy, 
though differing in some respects from catalepsy, as described above, 
appears to be only a modification of this latter disease, or at least 
not essentially diverse from it. In its general phenomena, ecstasy 
partakes both of the character of tetanus and catalepsy. In ecstasy, the 
whole mind is concentrated, and, as it were, fixed upon some par- 
ticular object, and the motific nervous influx is strongly and regularly 
determined upon the extensor and flexor muscles; so that no other 
impression can affect the mind, and the whole body remains rigid. 
Authors, however, differ in their statements with regard to the state 
of the muscular system. Good says, that in ecstasy " the muscles are 
thrown into a rigid and permanent spasm, not incurvating the body 
as in the different modifications of tetanus, but maintaining it erect 
from an equal excess of supply (of nervous power) to the extensor 
and flexor muscles." Richter, on the contrary, states that the limbs 
may be bent by extraneous force as in catalepsy; but they do not, as in 
this latter affection, continue in the position they are placed, but obey 
the laws of gravity.* The higher grades of ecstasy are sometimes 
attended with visions, apparitions, &c, and may continue for many 
hours.t Osiander speaks of a variety of partial cataleptic affections, 
which sometimes attacks a single extremity in young females about 
the age of puberty. The limb swells suddenly, becomes insensible, 
incapable of voluntary motion, but remains pliable as in true cata- 
lepsy.:): 

Causes. — This affection occurs much more frequently in females 
than in males. The period of life at which there appears to exist the 
greatest aptitude to catalepsy, is about the age of puberty. Persons 
of a nervous temperament, more especially when addicted to long and 
intense mental application, are said to be most subject to this affection. 

The exciting causes of catalepsy appear to be as various as those 
of epilepsy. The disease not unfrequently arises from the influence 
of mental affections, especially from disappointed love. Tulpius 
relates a case of this kind;§ and Schilling has collected similar in- 
stances || Violent anger, protracted grief, hatred, and sudden terror, 
have produced this affection.1T Long-continued and intense mental 

* Loc. cit.. bd. viii, p. 481. 

t Braumer, de Differentia Ecstaseos et Catalepseos — as quoted by Richter. 

X Osiander, Denkwuirdigk, &c., b. i. 

$ Observ. Medicar., lib. i, cap. xxii — as quoted by Van Swieten. 

II Disser. yEyrum ex Amore Catalepticum Factum Exhibens. (Richter.) 

1[ Richter, Specielle Therap., b. ix, p. 488. 



76 CATALEPSY. 

application has excited the disease.* Wepfer knew a young man 
who always became cataleptic when he applied himself to mathema- 
tical studies.! Fernelius saw a case brought on by; close study. Ke- 
pelled cutaneous eruptions, particularly itch and tinea capitis, have 
been known to give rise to this affection.^ Suppression or irregu- 
larities of the menstrual evacuation, appears to be one of the most 
common causes of catalepsy ; yet the catamenial disorder, as Richter 
observes, is probably itself often only a concomitant occurrence, de- 
pending, as well as the cataleptic affection, upon some other morbid 
condition, particularly on intestinal irritation. That irritation in the 
stomach and bowels is often the direct exciting cause of the disease, 
is abundantly demonstrated by the cases that have been published. 
Van Swieten mentions the case of a woman seized with " true 
catalepsy," to whom he was called. While standing by her "she 
suddenly vomited up two live round worms," and immediately the 
cataleptic affection ceased. § Similar cases are related by Thorn, 
Jawandt,|| Behrens, and others. IT A constipated and loaded state of 
the bowels also has been known to give rise to this affection. (Hirs- 
chel.) Catalepsy has been frequently found to occur in intermitting 
fever. Cases are related in which each paroxysm of this fever com- 
menced with a cataleptic state.** Van Swieten quotes a case of this 
kind from Dodonosus ; and Richter refers to Fleisch and Hirschel for 
similar instances. Tissot has seen catalepsy produced by carbonic 
gas. It is said to have been excited by pregnancy.tt General 
plethora ; organic affections within the head ; masturbation, &c, are 
also enumerated among the exciting causes of this disease. 

It would be in vain to enter into any speculations concerning the 
proximate cause of this affection. We may, indeed, observe, that 
there appears to be a complete dissociation between the moral and 
corporeal elements of the human system, so that the former can no 
longer be affected through the latter, or vice versa. At the same time, 
however, that the mind is thus incapable of being excited, or of ex- 
citing the body, the brain continues to secrete and transmit the motific 
influence to the muscular system, although its distribution is wholly 
beyond the control of volition. That the muscles are furnished with 
a regular influx of the nervous power, is evident from the fact, that 
the cataleptic patient, though entirely without consciousness and 

* The case already quoted from Galen was produced " by too much study.'' 
Van Swieten, loc. cit., t. x, p. 193. 

t Observ. Med. Prac. de Affect. Capites, obs. 66. 

% Burserius Instit, vol. hi. p. 137. Dufour. Journ. de Med., t. Ixx, p. 418. 

§ Loc. cit, t. x, p." 191. 

|| Hufeland's Journal, b. iv, st. iv, p. 784. 

IT [One of my patients, a delicate female, was attacked with general catalepsy 
from eating a quantity of charcoal, and, I am sorry to say, drinking gin and co- 
logne water. She was persuaded to discontinue these injurious practices, and the 
disease never recurred. — Me.] 

** Medicus Samml. u. Beobacht., b. ii, p. 372. (Richter.) 

ft Osiander, Entwicklungs Krankheiten, &c, b. i, p. 182. 



■1°.1 

CATALEPSY. 77 

sensorial power, will maintain not only an erect and firm posture, 
but support the extremities in positions in which they can be kept 
only by a regular and equilibrious action of the flexor and extensor 
muscles. The metaphysician might draw interesting inferences from 
the phenomena of this disease, concerning the essential distinction 
between mind and the mere physiological functions of the sensorium 
commune. This, however, is not the place to indulge in speculations 
of this kind. 

The prognosis in this affection cannot, in general, be regarded as 
very unfavourable. Van Swieten observes, " I have both seen from 
practical observations myself, and it appears from undoubted obser- 
vations of celebrated physicians, that a great many have recovered 
from this disease and afterwards enjoyed a perfect state of health."* 
Tissot makes the same remarks from his own experience. It may, 
nevertheless, terminate in fatal apoplexy, or in epilepsy, coma, melan- 
choly or mania, and occasionally, though very rarely, the cataleptic 
paroxysm has been known to terminate fatally without the superven- 
tion of any other affection. (Richter.) In protracted cases of cata- 
lepsy, the mind generally at last suffers more or less impairment of 
its powers; and in some instances, atrophy, emaciation, or dropsy, 
is its consequence. When the cataleptic paroxysm is succeeded by 
weakness and numbness in some part of the body — particularly of 
one or more of the sensorial organs, together with a sense of weight, 
fullness, and confusion in the head, or inactivity and absence of mind, 
the prognosis is particularly unfavourable with regard to its sanability ; 
and the same remark applies to those cases which alternate with 
chorea, mania, or epilepsy. The occurrence of spontaneous sangui- 
neous discharges — as hasmorrhois, epistaxis, or the catamenia, has 
been known to put a stop to the further recurrence of the disease. 
Those cases which come on about the period of puberty, often cease 
spontaneously after this stage of physical development has been fully 
passed over. Instances that depend on gastric irritating causes — 
such as worms, accumulated fecal matter, acrid secretions, or other 
movable, offensive substances, — are in general most easily cured. 

Treatment. — In general the treatment of catalepsy does not differ 
materially, either in its particular indications, or remedial measures, 
from that which has already been described under the head of epi- 
lepsy. When the paroxysm is protracted, small doses of sulphuric or 
acetic ether may be administered, if the power of deglutition remains, 
and there are no signs of cephalic congestion present. Great caution, 
however, is to be practised in the use of internal stimulants. Fric- 
tions along the course of the spine, fomentations or stimulating appli- 
cations to the feet, and enemata, may sometimes contribute to the 
removal of the paroxysm. When evident signs of vascular congestion 
of the head are present, and the pulse is not very feeble, blood should 
be taken from the arm, or by means of cups from the temples or back 
of the neck, and sinapisms or warm applications made to the feet, 
together with the use of purgative enemata. If a purgative can be 

* Commentaries, vol. x, p. 197. 



78 CATALEPSY. 

introduced into the stomach, it ought, by all means, to be done— more 
especially when there is reason to apprehend the presence of irritating 
matters in the intestinal canal. Reil states, that he once saw a girl 
affected alternately with mania and epilepsy, which instantly went 
off, on the expulsion of a number of lumbrici, by anthelmintics and 
enemata.* Galvanism and electricity, also, have been recommended 
in the cataleptic paroxysm ; but they must not be applied in a strong 
degree. Richter refers to an instance, related by Thorn, in which a 
young lady who was passionately fond of music, was roused from 
the cataleptic state by this delicious influence. Hard tones produced 
no effect on her, but soft and melodious ones brought tears from her 
eyes, and roused her as from a dream. 

The treatment proper during the intervals of the cataleptic parox- 
ysms, with the view of preventing their recurrence, should accord 
with the character of the occasional cause, the patient's constitutional 
temperament, and the state of the vascular system. In the cases 
that occur about the period of puberty in females, active or exciting 
remedies will seldom do any good, but, on the contrary, often prove 
decidedly prejudicial; and when such instances are connected with 
suppressed or irregular menstrual function, the active emmenagogues 
should be particularly avoided. (Richter.) A proper regulation of 
diet, country air, regular exercise, tepid bathing, sea-bathing, chaly- 
beates, and laxative mineral waters, will often do more in cases of 
this kind than any other course of remedial management. Where 
symptoms of gastric and hepatic derangement are present, the occa- 
sional use of four or five grains of blue pill, with a course of gentle 
laxative and tonic medicines, will often prove beneficial. A state of 
general plethora will require an abstemious mode of living, and 
abstractions of blood; verminous irritation demands anthelmintics; 
repelled cutaneous diseases call for external vesicating, pustulating, or 
irritating applications, with a gentle course of alterative and diapho- 
retic remedies ; and a general excitable and weakened state of the 
nervous system requires tonics, with antispasmodics, the narcotic 
extracts, or camphor, exercise in the open air, and the use of the 
tepid shower bath. Stark cured a case of catalepsy by assafoetida, 
galbanum, and infusion of the bulb of paeony; the extract of hyoscy- 
amus, oxyde of zinc, valerian, musk, castor, and opium, (Grenier,) 
have been successfully employed. Marx speaks very favourably of 
the powers of acorns in this affection. The sulphuret of iron, and 
belladonna, with the fetid gums, have been used with success ; and 
Loebstein-Loebel recommends the use of phosphorus. In short, nearlv 
every remedy that has already been mentioned under the head of 
epilepsy, has been advised, and may perhaps be beneficial in certain 
varieties of this disease. The nitrate of silver, the elutriated oxyde 
of tin, flowers of zinc, mercury, cuprum ammoniacum, and the vari- 
ous antispasmodic and narcotic remedies, have all been used and 
sometimes, it is said, with success. 

* Fieberlehre, bd. iv, p. 72. 



CHOREA. 79 



Sect V. — Chorea. — St. Vitus' s Dance. 

The first distinct account which was given of this disease is to be 
found in the writings of Plater and Sennertus, both of whom lived 
about the close of the sixteenth century.* Since that period it has 
been described under a variety of names, expressive of that peculiar 
saltant action of the extremities which characterizes the disease, 
such as chorea St. Modesti ; saltus viti ; choreomania; ballismus; 
orcheslromania ; epilepsia saltatoria; dance de St. Guy. 

The name St. Vitus's Dance, by which it is now familiarly 
known, was derived, according to Horst, from the chapel of St. 
Vitus near Ulm, to which women labouring under a certain nervous 
affection were in the habit of resorting every spring, where they 
danced violently and unremittingly from morning to night, until 
they sunk down completely exhausted, into a swoon, or kind of 
ecstasy, by which exercise they fancied themselves cured for one 
year. Some writers place its origin at a much earlier date, deducing 
it from the very remarkable dancing mania which prevailed through- 
out Germany in 1374, and which, as it was thought to be the mali- 
cious doings of Satan, was generally treated by exorcism ; and it is 
said that the monks of the convent of Korbey were particularly 
fortunate in casting out the fiend under the holy influence of their 
patron, Saint Veil. 

Chorea rarely, if ever, comes on suddenly. Its approaches are 
always gradual under a variety of premonitory symptoms, varying 
in duration from a few days to several months, indicative of a de- 
ranged state of the digestive organs and nervous system. The most 
common of these symptoms are slightly flatulent pains in the stomach 
or bowels, variable appetite, constipation, tumid and hard abdomen, 
occasionally vertigo, anxiety and a feeling of oppression in the prascor- 
dial region, slight tremors, and heaviness of the extremities, oppres- 
sion in the chest, frequent palpitations, visual illusions, fullness in the 
head with temporary confusion of mind, a feeling of tension in the 
forehead, itching in the nose, cold feet, variableness of disposition 
fluctuating between gloom and cheerfulness, and in some instances 
a remarkable proneness to mischievous and unruly conduct. 

After some or perhaps the majority of these manifestations of de- 
ranged health have continued for a longer or shorter time, irregular 
muscular twiches or spasmodic contractions are observed in the face 
or one of the extremities. These spasmodic actions are at first slight 
and only occasional, and are particularly noticed on the sudden oc- 
currence of any thing that flurries the mind. With more or less 
rapidity, however, they become stronger and more constant, until, at 

* It has been supposed that Hippocrates alludes to chorea in the following pas- 
sage, according to the version of Fccsius. " Medulla spina affecta homo nee 
crurum aut ventris officio potens est, nisi urgente necessitate; si vero morbus 
invaluerit turn aliquando praeter voluntatum mejit et egerit." 



SO CHOREA. 

times, almost every muscle of the body is in a state of continued in- 
voluntary action. Not unfrequently, the morbid muscular action is 
almost entirely confined to one side of the body ; and this is generally 
the left side. (Richter.)* From the imperfect command ot the will 
over the voluntary muscles, the patient, when he attempts to walk, 
has a starting, hobbling, and irregular gait, with an awkward drag- 
ging of one of the legs. Sometimes the involuntary muscular actions 
are so violent, and the empire of volition over them so completely 
lost, that progression, and even an erect posture, are rendered wholly 
impossible.t The hands and arms, too, are in constant motion ; the 
patient is often entirely unable to direct them ; and in all cases, various 
ineffectual efforts are made before the hand can be brought to the 
desired point. Thus, in conveying food or drink to the mouth, the 
hand is generally forced in almost every direction except the intended 
one, and is at last brought to the lips only after a number of unsuc- 
cessful efforts. 

The contractions of the muscles of the face are sometimes extremely 
severe and irregular, giving a continually varying expression to the 
countenance, often of the most ludicrous cast, and occasionally truly 
frightful. The head is sometimes thrown from side to side, or back- 
wards and forwards, the mouth suddenly widely opened and again 
forcibly closed, the tongue rapidly thrust out of the mouth and re- 
tracted, and the eyelids are in continued irregular motion. In violent 
cases, deglutition is much impeded, and, occasionally, for a short time 
entirely prevented, by the spasmodic action of the pharynx and 
oesophagus. Respiration also is often anxious and irregular; the 
voice is altered, and articulation is indistinct and stuttering. Almost 
every voluntary muscle, in short, is at times in a state of uncontrolla- 
ble and dissociated action. The authority and commands of volition 
are disregarded, and the whole muscular system is thrown into a state 
of revolt, its actions being irregular, lawless, and destructive to the 
welfare of the general constitution. 

At first the expression of the countenance, in the intervals of the 
spasmodic motions, " is that of good humour and contentment ;" as 
the disease advances, however, the eyes lose their wonted lustre and 
intelligence, the face becomes pale, expressive of languor, and at last 
acquires a fatuous expression. Fleisch observes, that in many in- 
stances patients affected with this disease evince a peculiar and ap- 
parently irresistible propensity to creep into holes, boxes or closets 

* Cases have been related, in which one leg and the arm of the opposite side 
alone were affected. ( Wocltche, Observationcs, Medicin. Fascicul., Richter.) 

t Occasionally all the muscles suddenly become completely relaxed ; and in- 
stances have been known where the extremities have been so violently distorted 
as to dislocate some of the joints. (Bruickman, Enerratio Chorea St. Viti et Epi- 
lepsia per Fontis Medicatos Emenses Curatce. Hufeland's Journal bd. iii st. iv p. 
612. Richter, Specielle Therapie, bd. vii, p. 735.) A case is mentioned in Bal- 
dinger's Magazine, st. xii, p. 1095, in which the elbow-joint was dislocated, and 
in a few minutes again replaced by the violent contortions of this disease. 



CHOREA. 81 

so narrow that it is sometimes difficult to extricate them from their 
confined situations.* 

The temper and mind almost always become more or less affected 
in cases of a protracted character, more especially in very young 
subjects. I have seen several cases in which complete and perma- 
nent weakness of intellect was the consequence of this disease. In 
some instances, the patient occasionally lapses into a kind of ecstasy 
or somnambulism. (Richter.) Slight paralysis sometimes occurs on 
one side of the body. Nearly three years ago, I attended a child 
affected with this disease, in which incomplete hemiplegia and amau- 
rosis in both eyes took place ; and it is only within the last ten 
months that these paralytic affections have wholly gone off. 

Sometimes chorea assumes very extraordinary forms. In some 
cases the patient is seized with paroxysms of violent dancing, leap- 
ing or stamping, accompanied with various antic contortions of the 
body; at others there is a rapid and forcible beating with the hands 
against some part of the body, particularly the knees ; occasionally 
an irresistible propensity to leap upon chairs, tables, and to clamber 
up the walls of the room, is manifested ; and patients have been 
known to stand erect and turn round like a top on the toes. Fever 
is not a necessary attendant on chorea, but when the disease con- 
tinues long, the muscles become wasted and flaccid, and in cases of a 
very obstinate and protracted character, slow febrile irritation ensues. 

During sound sleep, when volition is in a state of temporary sus- 
pension, (with regard to its influence over the voluntary muscles,) all 
the spasmodic motions which characterize this affection cease en- 
tirely. Indeed, the efforts of volition during the waking state often 
manifestly aggravate the involuntary action of the muscles. It 
would seem that the stimulus of the will is in some degree essential 
to the production of the irregular muscular motions. 

Chorea is a paroxysmal affection. In most instances several dis- 
tinct paroxysms occur daily at irregular periods, with little or no 
spasmodic action during the intervals. Sometimes, however, violent 
exacerbations take place once, twice, or oftener daily, with more 
or less of choreal action throughout the intervals. Occasionally, 
though indeed very rarely, the recurrence of the paroxysms is strictly 
periodical. t There is much diversity also in relation to the duration 
of the paroxysms. Sometimes they do not last more than ten or 
fifteen minutes; more frequently they continue for an hour or two, 
and occasionally they commence in the morning and do not cease 
until the patient sleeps at night. Cases have occurred in which the 
paroxysms continued with no obvious remission for six or seven 
days. J 

The touch of iron is said sometimes to have a very extraordinary 

* Handbuch der Krankheiten der Kinder, &c., b. iv, p. 419. Richter, loc. cit. ; 
p. 734. Wichmann, Ideen zur Diagnostick, b. i, p. 137. 
t Mead, Opera., torn, i, p. 32. 
% Vogel, Stark, Richter. 
VOL. II. 7 



82 CHOREA. 

effect upon this disease. Wichmann,* Richter, and others, assert 
that the peculiar spasmodic actions of this affection either cease in- 
stantly, or become greatly aggravated, if the patient places his hands 
on a piece of cold iron during the paroxysm; and Stark says that he 
has often known the same effect produced by sprinkling cold water 
on the patient, or merely by touching him with a cold hand.t 

Chorea appears to be verv closely allied to the taraniismus of 
Apulia, an affection which ha's, indeed, by some, been regarded as a 
mere modification of this disease.^ The beriberi of India, also, 
would seem to be somewhat similar to chorea ; and that singular con- 
vulsive affection, described under the name oirap/iania, which, from 
the latter part of the 16th to the middle of the 18th century, appeared 
in frequent and extensive epidemics in various parts of Germany and 
France, bore, in many respects, a close resemblance, in its chronic 
form, to the present disease. 

Whether those remarkable nervous and spasmodic affections, which 
have been known to result from religious enthusiasm or frenzy, are 
to be regarded as instances of chorea, is very doubtful. Many very 
extraordinary examples of this kind have been related. Wierus 
gives an account of a choreal affection which occurred among the 
nuns of the convent of St. Brigitta. They were seized with occa- 
sional paroxysms of screaming, dancing, leaping upon chairs and 
tables, and various other ludicrous contortions and motions of the 
body.§ The same writer gives the history of a somewhat similar 
affection, which prevailed in 1564, among the nuns of the convent 
Nazareth, near Koelln, the paroxysms of which were attended with 
very un-nun-like actions. " Infima corporis parte," says Wierus, 
"succusata ad eum modum qui veneri solet ascribi, oculis interim 
clausis," and it was concluded that nothing but the malicious work- 
ings of Satan could produce such mortifying and uncongenial pheno- 
mena. 

Dr. Robertson, in his inaugural dissertation, states, that some years 
ago, an affection, resembling chorea, appeared among a religious sect 
in Tennessee, in consequence of an enthusiastic and noisy mode of 
worship; and was extensively propagated by the influence of imagi- 
nation, or moral sympathy. || 

Causes. — Chorea very rarely attacks persons beyond the 20th 

* Ideen zur Diagnostick, bd. i, p. 153. 

t Handbuch zur Kentniss u. Heilung innerer Krankheiten & Th., iii, p. 164. 

X Swartz. Dissert, de Tarantismo, &c. Richter. 

$ J. Wieri, lib. de Prsestigiis, p. 378. 

|| The Rev. Mr. Hoge, in a letter to the Rev. Ashbel Green, of this city, dated 
September 10, 1801, speaking of the Methodist revivals, says: During worship 
the members of the meeting "drop down on every hand, shrieking, groaning, 
crying for mercy, convulsed; professors praying, agonizing, fainting, falling down 
in distress for sinners, or in raptures for joy ! No spectacle can excite a stronger 
sensation. I am told by the subjects of it, that a tremulous benumbing sensation 
seizes the extremities, particularly the fingers, which rapidly spreads through 
the system, the knees become feeble, the heart violently compressed, and the 
person drops to the ground." 



CHOREA. 83 

year of age ;* and its occurrence before the 8th year is equally un- 
common. Sydenham, Wichmann, and Thilenins, never met with 
this disease in children under ten years of age ; but its occurrence 
even in early infancy is unquestionable. About three years ago I 
met with an instance of well-marked chorea in an infant less than 
nine months old. This case was seen also by Dr. Parrish. Hamil- 
ton,! Gregory, and other writers, assert that the disease attacks girls 
and boys indiscriminately. Judging from my own observations, I 
should infer that females are by far more liable to it than males ; and 
this inference is supported by the observations of several eminent 
writers. Van Hoven makes the relative proportion of males and 
females affected with chorea, as about two to twenty. 

The constitutional habit, most favourable to the occurrence of this 
disease, is that peculiar excitable state of the common sensorium, 
constituting what is usually called the nervous temperament. It is 
said that a predisposition to chorea is sometimes hereditary, but this 
depends probably simply on the hereditary transmission of the gene- 
ral constitutional temperament. Cullen, Wichmann and Jahn J state 
that this otherwise not very common disease has been known to occur 
with unusual frequency during particular years or seasons ; and it 
has been supposed, from this circumstance, that certain atmospheric 
constitutions may create a predisposition to its attacks. 

The following are the principal exciting causes of chorea: 1. 
Mental emotions, particularly terror, fear, disappointed love, and 
religious enthusiasm. 2. Gastro-intestinal irritation from worms, 
accumulation of fecal matter, and other irritating substances lodged 
in the intestinal canal. Hamilton and other late writers consider 
this as by far the most common source of chorea. That the disease 
very frequently arises from causes of this kind admits of no doubt. 
Its origin from intestinal irritation is not, however, so common, I 
think, as is alleged by Dr. Hamilton. Certain I am, that in the ma- 
jority of instances that have come under my notice, the exciting 
cause did not appear to be located in the alimentary canal, and little 
or no advantage was derived from the remedies usually found bene- 
ficial in cases unequivocally dependent upon causes of this kind. 
Cases of chorea have been reported, which ceased almost immedi- 
ately on the expulsion of worms— particularly the tape-worm. § 3. 
Repelled chronic and acute cutaneous eruptions. Bisset, an Eng- 
lish physician, relates a case which came on in consequence of the 
repulsion of itch. Wendt saw an instance produced by the impru- 
dent drying up of tinea capitis; and other authors mention cases 
excited by repelled small-pox, and miliaria. (Richter.)|| 4. The 

* Dr. Powel knew an instance in which this disease occurred in a person in 
the 50th year of age. 

t On Purgatives, &c. 

•t Klinik. der Chronisch. Krankheit., bd. i, p. 245. 

$ Albers. Hufeland's Journal, bd. i. p. 152.— Baldinger's Neues Magazin., bd. 
ix, p. 189. 

|| A case of chorea consequent upon scarlet fever came under my observation 
recently and slowly yielded to remedies. 



84 CHOREA. 

suppression of habitual discharges, more especially of the menses. 
A case of chorea, in a girl about fourteen years of age, terminated 
fatally in less than three weeks. On dissection, the whole body of 
the uterus was found as hard as cartilage, and completely scirrhous.* 
5. Unsatisfied or over-excited sexual propensities. Richter states 
lhat chorea has been frequently cured by marriage. 6. Vegetable 
and mineral poisons have also been known to produce this affection. 
Stramonium, {Com ment. Litter. Norimburg, an. 1774,) mercury, 
(De Haen, Ratio Medend., torn, iii, p. 202,) and lead, have excited 
paroxysms of chorea. Dentition, pregnancy, parturition, and cold, 
are also mentioned among the exciting causes of this affection ; and 
it appears frequently to depend upon rapid corporeal evolution, or 
that peculiar change of constitutional habit which occurs at the age 
of puberty. 

The pathology of chorea derives little or no light from anatomical 
examinations. There are good reasons, however, for believing that 
it is essentially a cerebral affection. Its frequent occurrence from 
mental excitement; the intellectual weakness which almost invaria- 
bly results from its protracted continuance ; the suspension of the 
convulsive motions during sound sleep ; and its exclusive confinement 
to the voluntary muscles, point directly to the sensorium commune 
as the immediate source of the irritation upon which the spasmodic 
actions of the disease depend. Unquestionably, however, the cere- 
bral irritation is itself very frequently secondary, depending on a 
primary irritation, located in some remote part of the system, and 
frequently, perhaps, in the alimentary canal. In some cases which 
I have seen, it appeared to me that the irregular muscular motions 
were not so much the result of involuntary muscular actions as 
of an irresistible volition to perform these peculiar motions. In 
those instances of the disease, at least, that are characterized by leap- 
ing on tables, chairs, dancing, clambering up walls, and other similar 
actions, the propensity or will to do so appears to be irresistibly- 
exerted ; and we might, with some plausibility, ascribe the character- 
istic phenomena of the disease to a morbid action of the faculty of 
volition, depending generally on a sympathetic, and sometimes an 
idiopathic irregular excitement of the brain. 

Richter thinks that the proximate cause of chorea is seated in the 
system of ganglionic nerves, and particularly in the abdominal 
plexus. It is from this location of the primary irritation, he says, 
that the first manifestations of the disease generally occur in the 
feet ; that gastric and uterine irritation so frequently constitute its 
exciting cause ; and, finally, that those remedies which act more 
especially upon the abdominal viscera, are usually the most bene- 
ficial. All these circumstances may, however, be adduced with 
equal plausibility in favour of the cerebral pathology of this affection. 

Prognosis.— Chore* very rarely proves fatal, but it cannot be said 
to be entirely free from danger, as some writers have asserted.! I 

* Richter>sSpecielleTherapie,bd. vii,p 749, quoted from Wiegand's Magazin. 
fur Geburtsh., 1808, st. ii. 
t Wichmann, Baumes. 



CHOREA. 85 

have known one instance to terminate fatally, by the supervention 
of a slow and wasting irritative fever. Occasionally it is converted 
into epilepsy, and may prove fatal through the intervention of this 
affection.* The duration of chorea varies greatly. It may continue 
only a few days, or several weeks, months, or even years. The more 
violent and protracted the paroxysms are, and the more the mind 
has become affected by its attacks, the more difficult, in general, will 
it be to effect a cure. When the disease becomes very protracted in 
its course, it rarely fails to weaken the intellect ; and it has occasion- 
ally terminated in mental derangement, particularly in melancholy. 
Richter observes, that when chorea is complicated with other affec- 
tions — as chronic pectoral diseases, scrofula, fluor albus, and in gene- 
ral with a debilitated and shattered state of the nervous system, the 
prognosis is unfavourable. When it arises from the irritation of 
worms, or other substances in the alimentary canal, it is generally 
readily cured by proper remedial measures. It appears to be less 
apt to yield, when it has been excited by terror or other violent 
emotions of the mind. Instances that occur about the thirteenth or 
fourteenth year of age in girls, generally continue until the sexual 
development is completely accomplished. Cases of this kind, if left 
to themselves, almost universally terminate spontaneously after the 
regular establishment of the catamenia. When the disease is arrested 
by remedial treatment before the changes of puberty have been ac- 
complished, it is apt to return, and to manifest itself at intervals until 
the period of adolescence is passed. 

Treatment.— The principal indications in the treatment of chorea 
are, 1. To remove or counteract the exciting cause ; 2. To invigorate 
the general system; and 3. To break up the train of associated 
actions by which the paroxysms are repeated or continued. 

As the ordinary cases of chorea are almost always devoid of dan- 
ger, and often terminate spontaneously, after having for a considera- 
ble time resisted remedial treatment, it is not in general advisable 
to resort at once to very energetic remedies or modes of treatment. 
This observation applies particularly to those cases which depend on 
that peculiar constitutional metamorphosis which occurs during the 
period of puberty ; for we may calculate almost with certainty on 
the spontaneous termination of such cases as soon as this stage of 
corporeal development is fully completed.! 

Every one knows how strongly purgatives are recommended in 
the treatment of this affection, by Dr. Hamilton, of Edinburgh ; and 
this practice has since obtained pretty general approbation in Eng- 
land and in this country.:): When the bowels are in a torpid state, 
with an accumulation of fecal matter, free and repeated purgation is, 

* Weigand, Hamburg Magazin. Fuir. die Geburtsh., st. 1808. 

t The importance of attending to these circumstances is particularly insisted 
on by Richter. Specielle Therapie, bd. vii, p. 755. 

X The employment of active purgatives for the cure of this disease, was strong- 
ly recommended long before the time of Dr. Hamilton. Stark speaks highly of 
the good effects of very active purgation in this disease. (Acten d. Kurfuistl. 
Academie der Wissenshaften } 1776, p. 193.) Unzer also employed drastic 



86 CHOREA. 

without doubt, a highly important measure; and in all cases, indeed, 
laxatives must be regarded as useful auxiliaries. That the power ot 
this class of remedies as a curative measure, is, however, considerably 
overrated by Dr. Hamilton and others, I am much inclined to sus- 
pect. I have treated twelve or thirteen cases according to the plan 
laid down by this highly respectable writer, but have not, in more 
than two instances, derived the advantage from it that I was led to 
expect from his statements. As a preparatory and auxiliary mea- 
sure to tonic and other suitable remedies, moderate purging will 
rarely fail to do good ; but I question much whether any decisive 
impression can be made on this disease by purgatives alone, except 
in cases depending on intestinal irritation, from fecal accumulations 
or other irritating substances lodged within the bowels. Where the 
signs of gastric impurities, or of a loaded state of the bowels, are 
unequivocal, mercurial purgatives should be given daily, or every 
other day, until there is reason to believe that the offending matters 
are evacuated, and the biliary secretion improved.* After the 
bowels have been freely evacuated, tonics should be used in alter- 
nation with laxatives. The quinine, or any of the ordinary bitter 
infusions, will answer for this purpose. — Whytt says that he has 
known the supervention of diarrhoea to put a permanent stop to 
chorea ; and the very remarkable case, reported by Dr. Watt, after 
active purgatives and a great variety of other remedial means had 
been ineffectually employed, terminated at last on the occurrence of 
profuse spontaneous diarrhoea. (Med. Chir. Transact., vol. v.) 

In some instances, coming on from retained or suppressed men- 
strual evacuation, the general diathesis is manifestly phlogistic. Here, 
along with aloetic purges, it will be proper to bleed, and to put the 
patient on a mild vegetable diet, with an occasional dose of Dover's 
powder in the evening. About three years ago I attended a young 
lady who was seized with chorea, apparently in consequence of sup- 
pressed catamenia. Her pulse was small, sharp, and tense; the skin 
generally dry and warm, and the bowels constipated. I directed 
her to be bled to the extent of twelve ounces, and to take one of the 
pills, mentioned below,t every night, and a small dose of sulphate 
of magnesia every fourth day. In the course of two weeks she was 
bled four times, and the disease disappeared during the third week. 
The menses did not reappear until five weeks afterwards. 

purges with success in chorea. Sydenham treated this disease by purgatives and 
bleeding on alternate days, with an opiate at night (Schedula Monitoria de Nova 
Fcbris Ingrcssu, an. 1665.) 

* Hamilton recommends full doses of calomel and jalap. I have generally 
preferred using the following pills : 
R. — Extract colocynth. comp. gi. 
Calomel £ss. 

Tart, antimonii gr. i. — M. Divide into 20 pills. S. Take one. two or 
three, according to the age of the patient, every other day. 
t R. — Massae hydrarg. gi, 
G. aloes gss. 
Tart, antimonii gr. ii. — M. Divide into 20 pills. 



CHOREA. 87 

When the disease attacks persons of a highly excitable state of 
the nervous system, or of a strongly marked nervous temperament, 
peculiar benefit may often be derived from the cautious exhibition 
of antispasmodic and narcotic remedies. Valerian, assafetida in 
union icith quinine,* musk, hyoscyamus, camphor, and opium, 
under judicious management, will sometimes do much good in cases 
of this kind. 

In cases depending on suppressed catamenial discharge, attention 
must, in the first place, be paid to the alimentary canal. Laxatives, 
a mild and simple diet, with a few grains of blue pill at night, must 
be employed until the bowels and liver are brought to a healthy 
condition. When this is effected, recourse may be had to remedies 
more directly calculated to promote the flow of the menses — parti- 
cularly to turpentine, warm pediluvium, cantharides, blisters over 
the sacrum, small doses of aloest — and, where the general habit and 
pulse are languid, savin, and black hellebore. Richter says that in 
one instance of this kind, he gave twelve grains of borax three times 
daily, with speedy and complete success. It should be recollected, 
however, that retained or suppressed menstruation may accompany 
chorea, without having any agency in the production of this affection 
— the catamenial disorder being itself only a concomitant effect of 
some previous general morbid condition of the system. It will, there- 
fore, be more accordant with correct principles of practice, to endea- 
vour rather to remove that general morbid condition upon which both 
the menstrual irregularity and the convulsive disorder depend, than 
to make vain, and too often injurious, efforts to restore the menses 
with active emmenagogue remedies. When, therefore, relaxation, 
debility, or a general leucophlegmatic state is present, tonics, par- 
ticularly j>077,a regulated diet, ventilation, and exercise by gestation, 
should be chiefly depended on: and, on the contrary, where the 
diathesis is phlogistic, the body plethoric, and the skin dry and warm, 
recourse must be had to depletion, purgatives, a vegetable or fari- 
naceous diet, leeching about the pelvis, &c. 

When chorea arises in consequence of suppressed perspiration 
from cold, or the retrocession of cutaneous eruptions, antimonials, 
Dover's powder, camphor, warm aromatic ptisans,J the warm bath, 
blistering, rubefacient frictions, the internal use of sulphur, issues or 
setons, and a warm and equable temperature, or appropriate reme- 

* Within the present year I have seen very decisive advantage obtained from 
the use of the following pill, taken every four hours, after proper evacuations had 
been premised : 

JR. — Sulphat. quina; ^i. 

(i. assafetid. Bii— M. Divide into 20 pills. 

t The compound tincture of aloes, in closes of from 15 to 20 drops three times 
daily, is one of the best aloetic preparations for this purpose. Small doses of 
hiera-picra, also, frequently answer peculiarly well, when there is considerable 
weakness of the stomach present. 

"J Infusions of elder blossoms, eupatorium perfoliatum. catnep, sage, marjorum, 
balm, &c, will answer well for this purpose. 



8S CHOREA. 

dial measures. It is scarcely necessary to say, that where vermi- 
nous irritation is manifestly present, anthelmintics should be used. 
In instances that are excited by mental emotions, musk and opium 
are said to be particularly calculated to do good. 

Considerable advantage may sometimes be obtained in the treat- 
ment of chorea, whatever be its exciting cause, from external appli- 
cations—such as dry frictions with flannel, or blistering, or rubefa- 
cients, along the course of the spine ; stimulating baths ; the cold 
shower-bath, and sea-bathing. The cold shower-bath, after a proper 
course of evacuants, and in connection with the internal use of tonics, 
will generally contribute materially to the re-establishment of health. 
Frictions with tartar emetic ointment over the region of the spine, 
have been resorted to with entire success in some very severe and 
protracted cases. Mr. Hunter, of Glasgow, {Med. Recorder, vol. 8,) 
has reported an interesting case, which, after many ineffectual trials 
with other remedies, was speedily subdued, by pustulation with this 
ointment on the scalp, and over the spinal column. Dr. Wharton, 
of Virginia, also, has related a case which yielded to this treatment. 
{Med. Recorder, No. 33.) In the fifth volume of the Jimer. Journal 
of the Medical Sciences, Dr. Byrne, of Baltimore, has given an 
account of two protracted and obstinate cases of chorea, in which 
pustulation along the course of the spine effected speedy cures. The 
first case had continued nearly two years — the mind was evidently 
impaired, "the appetite was bad, the tongue foul, and the bowels 
irregular, generally costive." The patient, a girl, was 13 years old, 
and had as yet never menstruated. The purgative plan of treat- 
ment was fully tried ; afterwards, she was put on the use of tonics 
and antispasmodics, and finally subjected to a slight mercurial course. 
No advantage, however, was derived from these remedies. Strong 
tartar emetic ointment was then rubbed in along the whole spinal 
column, and repeated three times daily. " On the evening of the 
second day the eruption began to appear, and from that time to the 
present, the patient has never been affected with the slightest irregu- 
larity of muscular motion. Her mental faculties, in a short time, 
resumed their wonted energy, and her health was perfectly restored."* 

If our endeavours to remove the disease, by a course of treatment 
founded on the indications furnished by the character of the exciting 
cause and the general state of the system, prove abortive, we may 
then resort to what the Germans, with strict propriety, call the em- 
pirical remedies, recommended in this affection. 

Among these, the flowers of zinc have, perhaps, been most fre- 
quently employed, and favourably mentioned, as a remedy in chorea. 
Burserius,t Hand, Richter,! Stark and Alexander relate instances 

* [In a very obstinate and violent case of chorea complicated with rachitis, I 
once applied the actual cautery to the spine with prompt success. The patient 
was a delicate little girl, 9 years old, the daughter of Mr. John M/Donel of this 
city.— Mc] 

t " Nuper confirmatam et numeris omnibus absolutam choream St. Viti solo 
floram zinci usu ; tuto, cito et cucunde curavi." Institut. vol. iii p. 242 

% Medic, and Surg. Observat, p. 153. $ Duncan's Annals. 



CHOREA. 89 

of the successful employment of this article in chorea, and Dr. Bed- 
dingfield asserts that thirteen out of fourteen instances of this disease, 
in which he gave this remedy, yielded permanently to its influence.* 
In my own practice I have never obtained any decided benefit from 
this article. The sulphate of zinc, however, removed the disease 
speedily and permanently in one instance that came under my no- 
tice. The patient, a girl about twelve years of age, had already 
been affected with the disease for upwards of nine months, and had 
undergone various modes of treatment. A grain of this preparation 
was given three times daily ; and, without any other remedies, the 
disease disappeared in less than ten days. A case is related which 
yielded speedily under the use of this article, given in doses of three 
grains, mornings and evenings.f 

Cuprum ammoniacum has also been used with success in chorea. 
Willan cured a case in a very short time with this article.^ 

The nitrate of silver has succeeded in removing this affection. I 
have used this article with success in a case that was excited by 
terror ; but in no other instance has it appeared to be beneficial in 
my hands, although I have employed it in eight or nine cases at 
least. Dr. Franklyn cured a case of chorea by the conjoined employ- 
ment of this article and cold affusions, {Land. Med. and Phys. Jonrn., 
No. lxviii ;) and Dr. Powell used it with marked advantage in this 
affection. (Transact. Lond. College of Phys.,vo\. iv.) 

The rust of iron will sometimes succeed better than any other 
remedy of this kind in the removal of this affection. The little pa- 
tient, whom I have already mentioned, was cured by this article. 
I had employed a course of purgatives, the nitrate of silver, flowers 
of zinc, and vesication along the spine and on the back of the neck, 
without any apparent benefit. By the advice of Dr. Parrish, the 
rust of iron was given ; in less than three days a very decisive im- 
pression was already made on the disease, and in about three weeks 
all the convulsive motions were removed. I have since used this 
article in two instances with success. One of these, a little girl, was 
cured by it about two years ago. Within the last six weeks, she 
has again been seized with the disease, and in this attack I have 
not been able to obtain any advantage from the iron. It should be 
given in large doses. Dr. Elliotson administered this article in very 
large doses — from a drachm to half an ounce three times daily. He 
relates eight cases, all of which were cured by this remedy. (Med. 
Chirurg. Transact., vol. xiii.) 

Ckenopodium ambrosioides has been highly extolled for its pow- 
ers in this disease. It was first recommended by Plenck, and has 
since been used very successfully by Mick, Ecker, and others.§ It 
is given in powder from one scruple to a drachm, two or three times 
daily. || 

* Compendium of Medical Practice. Part i, chap. x. 

t Memoirs of the Med. Society of Lond., 1773, vol. x. 

% Lond. Med. Journ., vol. iii, p. 11, p. 187. 

$ Pinel'B Nosography. — Translated into German by F. V. Ecker. 

II I have used this plant in several cases of chronic hysteric affections with 



90 CHOREA. 

Camphor.— No small number of cases have been published illus- 
trative of the good effects of this article in chorea. Pitt used it suc- 
cessfully in combination with valerian ; and Wilson {Med. Comment., 
Edinb", vol. ii), reports a case which yielded under the employment 
of camphor and assafcetida. Richter says that this article is particu- 
larly useful in cases attended with seminal irritation, or in such as 
are produced by inordinate venereal indulgence. 

A variety of other remedies are said to have been used with 
advantage in this affection. Werlhof cured the disease with the ani- 
mal oil of Dippel* Cardamine pratensis is recommended by 
Michaelis and Naegel ; Stoll recommends the extract of belladonna, 
and Dr. Kerrison succeeded in curing an obstinate case with it.t 
Stramonium has been successfully employed in this affection by 
Kreysig, Hufeland, Odhelius, and Sidren.J 

Fowler's arsenical solution proved very beneficial in the hands of 
Dr. Newnham.§ Dr. Raven has published four cases in which the 
tincture of colchicum was used with great benefit. || In one instance 
of a violent grade in a girl aged about seventeen, he gave 40 drops 
of this tincture every four hours. On the third day after commenc- 
ing with this remedy the disease was already nearly subdued ; and 
by continuing its use in gradually augmented doses, perfect health 
was restored to the patient. A very remarkable case is related by 
Dr. K. Wood, in the seventh volume of the Medico-Chirurg. Trans- 
actions, which was cured by beating a drum during the paroxysms. 

Dr. Young has reported some cases of this disease which yielded 
speedily to the use of the root of actea racemosa (cimicifuga race- 
mosa). He gave a teaspoonful of the powdered root, three times 
daily. " This remedy, he says, appeared to arrest the progress of the 

marked benefit. I usually employ it in the form of infusion — an ounce of the 
herb to a pint of boiling water — in doses of a wineglassful four or five times 
daily. It is particularly useful in cases attended with a feeling of numbness in 
the extremities, and with much gastric disturbance from flatulency. 

The chenopodium ambrosioides is one of the most common weeds in the 
neighbourhood of this city. It grows in the streets and along the fences in almost 
every part of the suburbs. 

* Observ. de Febrib., sect. ii. 

t London Medical Repos., No. xxxiv, art. ii. 

% Ausfuhrliche Arzneimittellehre. Von Dr. Geo. Aug. Richter, b. ii. p. 589. 

§ London Med. Repository, No. xlii. [In all distinctly periodical forms of 
chorea, the arsenate of potass is found to be efficacious. Certainly when the 
cutaneous function is impaired and the pulse is excited, it is appropriate. I have 
succeeded in several inveterate cases of this kind. In some instances, after due 
regulation of the secretions, I have used quinine and other preparations of bark 
with success. Their attendant anemia is soon overcome by chalybeates. im- 
proved diet and exercise out of doors. Gymnastic exercises are particularly 
serviceable in the way of restoring the energy of the muscles. Mr. Braithwaite 
says that the remedy for chorea is the carbonate or sesquioxide of iron, especially 
when administered in any bitter infusion. — Mc] 

II Lond. Med. and Phys. Journ., xxxvi., Sept. and Oct. 1816. 



CONVULSIVE AFFECTIONS OF INFANTS. 91 

disease almost at once. After using it only two days, one of the pa- 
tients was visibly benefited, and was entirely cured in five days."* 
Electricity has also been recommended for the cure of chorea. De 
Haen states that he has known great benefit to result from the 
application of this agent ; and Fothergill has published some remarks 
illustrative of its good effects in this disease.! Galvanism, also has 
been recommended; and Richter asserts that music has sometimes 
produced astonishingly tranquilizing effects in this disease. 



Sect. VI. — Convulsive Affections of Infants. 

At no period of life are convulsions so apt to occur as during the 
age of infancy. With a nervous system peculiarly excitable, infants 
are subject to so many sources of permanent and transient irritation, 
that a very large portion of them suffer more or less from convulsive 
affections ; and these constitute an alarming proportion in the cata- 
logue of fatal infantile maladies. According to the statement by the 
late Dr. Clark, of Dublin, it appears that of 17,650 children born in 
the Dublin lying-in hospital, one-sixth part died during the first year; 
and of those who died, nineteen out of twenty perished by convul- 
sions. This proportion of mortality from convulsions, however, 
very greatly exceeds that which a similar estimate drawn from pri- 
vate practice would yield. Still the frequency and fatality of this 
affection, under its various forms, are by no means inconsiderable in 
every rank of society, and under every variety of climate and exter- 
nal circumstances. Both the anatomical and physiological pecu- 
liarities of the infantile system are indeed such as to account for the 
especial aptitude to convulsive maladies during this tender period of 
life. The mind and body of an infant, not yet inured to the impres- 
sions of internal and external causes, possess the most lively suscep- 
tibility to the various perturbating and exciting influences to which 
it is unceasingly subjected. " The muscles, during infancy, are pale, 
soft and fragile ; their contractions quick, frequent and feeble ; and 
the external surface of the body is endowed with a very high degree 
of sensibility. The circulation of the blood is very rapid, and the 
capillary system is peculiarly active. The lymphatic system exerts 
a more powerful influence upon the general economy of the infant 
than upon the adult. The nerves are large, in proportion to the size 
of the body, and resemble medullary pulps. Both the cerebral and 
ganglionic nerves are much more strongly developed in relation to 
the body than at any other period of life. The brain is large, and 
the nerves which proceed from it are of a very considerable size. 
The sensations of a child are quick and transient; slight impressions 
give rise to powerful effects; and when reaction takes place, it is 
strong and sudden, and coincides with the general mobility of the 
infantile system.''^ 

* American Journ. of Med. Scien., vol. xii, p. 57. 

t Philosophical Transactions, for the year 1779. 

% North, on the Convulsive Affections of Children, p. 11. 



92 CONVULSIVE AFFECTIONS OF INFANTS. 

Mr. North observes that the children of parents who marry either 
very early, or at an advanced age, are more hab e to convulsive 
affections than the children of those who marry in the prime o lite. 
I have met with very striking instances of aptitude to convulsions 
in several families, which accord entirely with this observation. It 
has also been said that convulsions are much more common in cities, 
and particularly in the higher and more luxurious classes of society, 
than among the laborious and less pampered inhabitants of the coun- 
try. Of this, there can scarcely exist a doubt. The fresh and pure 
air of the country has an especial tendency to invigorate the infantile 
system, and to diminish nervous irritability, and thus to render the 
ordinary causes of convulsions less apt to excite such affections. It 
is, perhaps, mainly from the want of a pure and wholesome air in 
hospitals, that convulsive diseases are so much more common in these 
institutions than elsewhere. That the predisposition to convulsive 
affections is often hereditary, is amply demonstrated by observation. 
We occasionally meet with families in which the occurrence of re- 
peated paroxysms of convulsions is almost a matter of course in all 
the children, as they successively pass through the process of primary 
dentition; and on the other hand, in very many families, blessed with 
a numerous offspring, such affections never occur, although the ordi- 
nary exciting causes may be conspicuously present. The children 
of mothers endowed with a very susceptible physical and moral 
constitution — with a quick and active imagination, great sensitive- 
ness and mobility of temper, are in general most apt to suffer con- 
vulsive affections. Observations have also been made in relation to 
the configuration and size of the head, as an indication of the natural 
aptitude to affections of this kind. It has been said, for instance, 
that children who have very large heads are more liable to convul- 
sions than those who are less liberally furnished in this way. This 
observation, however, is, I believe, wholly without any foundation. 
Exciting causes.— The exciting causes of convulsions are ex- 
tremely various. In general, whatever is capable of causing strong 
sanguineous determinations to the brain, or of producing nervous 
irritation of the sensorium commune, may give rise to convulsive 
affections in children. The vascular turgescence of the brain, which 
in adults causes coma, or apoplexy, is apt, during the infantile period, 
to produce general convulsions. Even a moderate degree of sangui- 
neous engorgement of the brain is frequently productive of convul- 
sions in children predisposed to the affection. This is often illustrated 
by the occurrence of strong convulsions in fevers of strong vascular 
reaction, and particularly in the cold, and sometimes hot stages of in- 
termittents. In very young children, the paroxysms of an ague are 
very often ushered in by convulsions. I have known instances in 
which paroxysms of convulsions occurred periodically for four or five 
days before the nature of the malady was understood. 

In some instances, however, the disease arises from cerebral or 
nervous irritation, without any extraordinary sanguineous determi- 
nation to the head; and these are, in general, the most serious and 
unmanageable cases. This cerebral irritation is usually purely sym- 



CONVULSIVE AFFECTIONS OF INFANTS. 93 

pathetic, depending on a primary local irritation seated either in the 
alimentary canal, or in some other part, more especially in the gums 
from dentition. It must be observed, nevertheless, that both intes- 
tinal irritation and dentition are very frequently attended with an 
increased determination of blood to the brain; and the latter espe- 
cially is but very rarely unaccompanied by this additional source of 
cerebral disturbance. 

When an attack of convulsions is preceded and attended with a 
flushed and turgid countenance, dilated pupils, a full and active, or 
a contracted, frequent and tense pulse, with strong beating of the 
arteries of the neck and temples, and a warm and dry skin, we have 
conclusive evidence that the cerebral irritation which causes the con- 
vulsions is mainly, if not wholly, produced by vascular turgescence 
in the brain. In such cases, the child generally remains in a lethargic 
state, for a logger or a shorter time after the subsidence of the con- 
vulsions. When, on the contrary, the countenance is pale and the 
pupils contracted, the skin cool or of the natural temperature, the 
pulse small, frequent, quick and irregular or feeble, we may infer that 
the attack is not dependent on sanguineous irritation of the brain, but 
the result of nervous irritation, transferred to the common sensorium, 
most probably from a primary nervous irritation, located in the in- 
testinal canal. 

Among the most common exciting causes of this affection are : 
worms, and various other irritating substances lodged in the aliment- 
ary canal, such as acid, indigestible articles of food, over-distension 
of the stomach, acrid intestinal secretions, &c. Repelled cutaneous 
eruptions, and suppressed discharges from ulcers or excoriations, 
particularly when seated behind the ears. General plethora, with 
a predisposition to irregular sanguineous determinations to the brain. 
Dentition. — Irritation from the latter cause is incomparably the most 
frequent source of convulsive affections during infancy. Convulsions 
not unfrequently occur in the acute exanthema tons affections, either 
just before the eruption is about making its appearance, or in conse- 
quence of the sudden recession of the exantheme, before the period 
of its regular declension. Convulsions may also be excited by a direct 
or mechanical injury of the brain. I have known several instances, 
where a fall on the head, so as to cause considerable concussion of 
the brain, almost immediately gave rise to general convulsions, with- 
out any permanent or fatal lesion of the brain. Even severe local 
injuries of parts situated remote from the encephalon will sometimes 
excite an attack of convulsions. 

In some cases, a slow and insidious vascular irritation will go on 
in the brain, with scarcely any decided symptoms of disease, until 
either an effusion of serum upon the surface or into the ventricles of 
the brain, or some other cerebral lesion, is effected. In cases of this 
kind, a paroxysm of convulsions is sometimes the first unequivocal 
intimation of the child's indisposition ; and what was previously con- 
sidered as mere fretfulness and general irritability of temper, of no 
serious import, now suddenly assumes the character of an almost 
hopeless form of cerebral disease. Cases of this kind, however, are 



94 CONVULSIVE AFFECTIONS OF INFANTS. 

almost invariably connected with more or less paralysis, and fre- 
quently with strabismus, and must be regarded rather as insidious 
instances of hydrocephalus or of cerebral inflammation, than as con- 
vulsions of the ordinary form, of which I am now speaking. 

The prognosis of infantile convulsive affections must depend 
mainly on the nature of the exciting cause, and the violence and 
duration of the attack. Cases arising from a primary irritation located 
in the alimentary canal, or from the irritation of dentition, are cete- 
ris paribus, always less dangerous than instances depending on a 
primary irritation or lesion of the brain, or its spinal prolongation. 
Even purely sympathetic irritative convulsions, arising from intestinal 
or dental irritation, may terminate fatally, by the shock and structural 
lesion which the brain may receive from the violent determination of 
blood which in some instances takes place to the vessels of the ence- 
phalon. This is more particularly apt to be the case ki children of a 
corpulent and very plethoric habit, and where the convulsive attacks 
are of a protracted duration. In ordinary habits, there is but little to 
be apprehended from convulsions during infancy when the attacks 
are slight and of short duration ; and this observation applies espe- 
cially to those instances which, instead of leaving the infant in a dull 
and lethargic condition, are almost " immediately succeeded by the 
natural cheerfulness of the child." (North.) When death occurs 
suddenly during a paroxysm of convulsions, we almost always per- 
ceive manifest signs of strong sanguineous congestion in the vessels 
of the head — such as a darkish and turgid aspect of the face, fullness 
of the veins of the neck and head, heavy and almost stertorous breath- 
ing; and in such instances, the little patient dies " in a state nearly 
allied to apoplexy in the adult." The reviewer of Dr. North's excel- 
lent treatise on this affection, asserts that he has made more than thirty 
dissections of children who had died of convulsions, and that he in van- 
ably found the vessels of the encephalon strongly engorged with blood, 
attended with more or less serum in the ventricles of the brain ; and, in 
several cases, " considerable extravasation of blood from a ruptured 
vessel" was detected.* When paralysis and squinting occur, the most 
serious cerebral lesion may be inferred, and the prognosis is, of course, 
of the most unfavourable kind. Convulsions that come on suddenly, 
without any premonitory symptoms, are, in general, much more apt 
to terminate favourably than those cases which supervene after a 
considerable period of slight indisposition — such as great fretfulness, 
starting from sleep, grinding the teeth, occasional flushes on one or 
both cheeks, a variable appetite, deranged state of the bowels, &c. 

Before I go on to speak of the treatment of the convulsive affec- 
tions of children, it will be necessary to give an account of a very 
singular form of spasmodic or convulsive disease, occurring in chil- 
dren during the period of lactation. This affection was, I believe, 
first distinctly noticed by Dr. John Clark, of Dublin, in his Com- 
mentaries. About sixteen years ago, an interesting paper was pub- 
lished by Dr. Kellie on this subject ;t and at a subsequent period, 

* Medico-Chirurgical Review. July, 1826, p. 157. 
t Edinburgh Med. Journal, vol. xii. 



CONVULSIVE AFFECTIONS OF INFANTS. 95 

Dr. James Johnson published some observations on the disease of a 
very interesting character.* The most satisfactory account of this 
remarkable form of convulsive disease that has as yet been given to 
the public is to be found in the treatise of Dr. North, already quoted 
in several places. Dr. James Johnson denominated this affection 
carpo-pedal spasm; others have designated it as a form of cerebral 
spasmodic croup; and Dr. North has treated of it under the head, 
A spasmodic affection of the chest and larynx in young children, 
accompanied by general or partial convulsions. The following 
are the phenomena and general course of this affection, as detailed 
by Dr. North, and in the interesting paper on this subject published 
by Dr. Kellie. 

The disease generally occurs between the third and seventh month 
of age. It usually makes its approaches in a very gradual manner. 
At first the symptoms are often so slight, as scarcely to attract the 
attention of the persons about the infant. Among the earliest symp- 
toms of the approach of the disease is a very peculiar hurried breath- 
ing, accompanied "by that kind of noise which an increased secre- 
tion of mucus in the air-passages would produce," occurring at the 
moment the child wakes from sleep. Frequently the child awakens, 
as in a fright, and is immediately affected with this agitated respira- 
tion, and rattling in the trachea. " If the little patient has previously 
enjoyed a good state of health, the characteristic rotundity of fea- 
ture observable in infants quickly undergoes a remarkable change ; 
the countenance becomes anxious, the sides of the nose are drawn 
in, the face is pallid and emaciated, the child frowns almost con- 
stantly, and when put to the breast, it sticks greedily for a mo- 
ment, but suddenly ceases to do so, throwing back the head loitk 
violence.'' The bowels always become constipated in the progress 
of the disease. These symptoms may recur, with more or less fre- 
quency, for a very considerable time, before any remarkable change 
takes place, indicative of a further development of the affection. "A 
convulsive motion of the hand is usually the next morbid sign which 
excites attention. The child's thumbs will be found constantly and 
firmly pressed upon the palm of the hand ; the wrists and ankle-joints 
are bent rigidly inwards; the head is often thrown backwards, by 
which the anterior muscles of the neck are kept painfully upon the 
stretch. The inconvenience at the moment of waking is not now a 
mere acceleration of breathing. This symptom still continues in an 
aggravated degree — but the noise accompanying the respiration has 
gradually assumed a very different character from that which at first 
marked it. Each inspiration is now attended by a loud crouping 
noise, which may be heard in an adjoining apartment ; the chest and 
larynx appear to be painfully constricted ; the heart palpitates vio- 
lently; the child sobs, but never cries in its natural manner during 
these paroxysms of suffering. So great is the difficulty of breathing, 
that it sometimes appears to be almost totally suspended for a few 
seconds. The countenance is then pale, as in syncope. Sometimes, 

* Med. Chir. Journal, vol. iii, 1817. 



96 CONVULSIVE AFFECTIONS OF INFANTS. 

though rarely, the face is dark, and the vessels of the head and neck 
turgid, as in apoplexy. As the disease advances, the little patient 
experiences more or less frequent attacks of general convulsions, 
during which the features are much distorted : and the whole body 
is occasionally implicated in the convulsive movements. In a child, 
in whom the convulsions were very frequent and severe, the state of 
opisthotonos was so complete, that for many days the head and heels 
were the only parts which touched the bed; and if, with difficulty, 
this apparently painful position was altered by the mother, it was 
quickly resumed. In the majority of cases, no sustained febrile action 
is to be detected, nor is there usually any indication of particular de- 
termination of blood to the head."* Sometimes, the locked state 
of the thumbs, rigidly bent position of the hand and foot, and stri- 
dulus or croupy respiration, will continue several weeks with 
scarcely any intermission, though irregular intervals of remission and 
exacerbation are always more or less conspicuously noticed. " The 
child sometimes appears lively for a short period, and the counte- 
nance may be animated by a momentary gleam of cheerfulness ; but 
it almost invariably awakens from its slumbers, however tranquil 
they may sometimes appear, with a convulsive paroxysm similar to 
that described above." After the termination of a paroxysm, the 
child appears to be greatly exhausted, and with scarcely the power 
of voluntary motion for some time. Dr. Kellie's description of this 
affection is somewhat different from the one just given from Dr. 
North's work ; but in the main and characteristic phenomena, they 
coincide sufficiently to enable any one to refer it to one and the same 
form of infantile disease. " On the anconal aspect of the metacarpus 
of the hand," says Dr. Kellie, * and on the rotular aspect of the meta- 
tarsus of the foot, a remarkable tumour occurs, having a considerable 
degree of roundness and elevation, resembling that sort of swelling 
which might arise on the same parts from a blow or contusion. It 
seems to rise suddenly, and when first observed, it has somewhat of 
a mottled livid and purplish colour, resembling the chilled hand of 
a full and healthy child after exposure to a cold and frosty atmo- 
sphere. It has no inflammatory heat, and does not appear to be mor- 
bidly sensible, or to give any pain to the child when handled ; nor 
does it pit on pressure, but rather gives the sensation of firmness and 
resistance. When an attempt is made to move it sideways, under 
the skin, it conveys the notion of a disease peculiar to infants, known 
by the name of skin-bound. These tumours terminate abruptly at 
the carpus and tarsus, so that in lusty children it seems, in these 
places, as if confined by a cord or bandage. They sometimes con- 
tinue for two or three weeks ; occasionally they disappear in a few 
days ; and in other instances, they disappear and reappear at short 
intervals. The tumour sometimes becomes leucophle^matic loose, 
with considerable oedema spreading upwards on thele°-s. This, 
however, never occurs unless the swelling continues for several 
weeks without abatement ; but its more sudden disappearance with- 

* North, loc. citat. ; p. 259. 



CONVULSIVE AFFECTIONS OF INFANTS. 97 

out undergoing these changes, or without passing into a state of 
leucophlegmasia, is by far more common. This swelling on the 
tops of the hands and feet is connected, in a great proportion of cases, 
with a spastic contraction of the flexor muscles of the thumbs in 
the upper, and the toes in the lower extremities. The thumb becomes 
rigidly contracted, and permanently bent downwards and laid flat 
upon the palm of the hand; and, in like manner, the toes are bent 
down to the plantar aspect of the foot. Along with the thumb, the 
carpus is also in some cases drawn inwards by a spastic contraction 
of its flexors.* 

In Dr. James Johnson's case,t the child (nineteen months old) was 
seized three or four times in the hour, "with spasmodic affections of 
the respiratory muscles, consisting of repeated attempts to fill the 
chest, during which she threw herself back, as in opisthotonos, and 
appeared as though she would be suffocated. These fits wo.uld last 
ten or twelve minutes, after which, the child was somewhat easier, but 
always fretful and peevish. The backs of the hands and insteps were 
swollen and hard ; the thumbs rigidly contracted, and locked across 
the palms of the hands ; the toes were bent down towards the soles 
of the feet; and both wrists and ankles were firmly bent by the con- 
traction of the flexor muscles. The bowels were torpid ; the stools 
clayed or slimy and offensive; and the child was extremely irritable, 
both by day and by night." During the preceding summer, I met 
with an instance of this affection, in a child about nine months old, 
in other respects of a remarkably vigorous and robust state of health. 
The symptoms of this case coincided so closely with those mentioned 
in Dr. Johnson's case, that his description applies in every point to its 
phenomena and course. 

It does not appear that this singular affection is attended with much 
danger, when timely aid is afforded with proper remedial means. 
Dr. North had seen but one fatal instance of this malady ; and Dr. 
Johnson states, that in his own practice no instance of death has 
occurred from it. The case which came under my own observation, 
terminated favourably, after the process of primary dentition was 
completed. It should, nevertheless, be regarded as a disease of an 
unfavourable tendency ; for it cannot be doubted that the cerebral 
irritation which gives rise to its characteristic phenomena, may, under 
certain stages of predisposition, and in co-operation with other causes, 
tending to encephalic disease, readily pass into a state of vascular 
irritation, or sub-inflammatory action in the brain, or its meninges, 
and thus ultimately give rise to fatal effusion, or lesion in the brain, 
or its spinal prolongation. 

In the only dissection which is reported by Dr. North, the traces of 
cerebral disorder were sufficiently conspicuous. The vessels of the 
brain were very turgid ; a small portion of blood was effused under 
the dura mater in several parts ; a small quantity of serum was found 
in the ventricles ; and the whole mass of the cerebrum was unusually 

* Dr. Kellie, loc. citat. 

t Med. Chir. Journ., May, 1817, pp. 448, 449. 

VOL. II. — 8 



98 CONVULSIVE AFFECTIONS OF INFANTS. 

firm, while the cerebellum was softer than common. The thorax 
was not examined. Dr. North ascribes the inordinate determination 
to the head, and the evidences of encephalic disorder presented on 
dissection, in this case, to an accidental and overwhelming "rush of 
blood to the head, caused by a very passionate fit of crying," just 
before the occurrence of the last and fatal paroxysm. He thinks the 
characteristic phenomena of the disease are entirely independent of 
cerebral derangement, and that "in the majority of cases, there is no 
evidence of affection of the brain,"' and that we have no right to as- 
sume that certain individual symptoms— such as the crouping noise 
or bent thumb, must yiecessarily be followed by affection of the 
brain. 

From a general view of the phenomena of the malady, it appears 
to me, nevertheless, highly probable, that the disease is ctb initio, and 
essentially connected with nervous irritation of the sensorium, pro- 
pagated at last in very violent cases to the spinal cord. The frown- 
ing aspect of the countenance — the starting from sleep — the peevish 
and fretful temper — the occasional flushing of one cheek mentioned 
by Kellie, the costiveness and hepatic torpor, &c, all seem to indicate 
a state of nervous irritation or erethism of the brain; and the opistho- 
tonic spasms, which are wont to supervene in aggravated cases, point 
very directly to irritation of the spinal cord. 

Whatever may be thought as to the proximate cause of this affec- 
tion, all writers on this subject agree in ascribing its origin to dental 
irritation. It seems to be much more apt to occur in children of a 
robust and full habit of body than in such as are of an opposite con- 
stitution. So far as I have been able to ascertain, the disease has 
never been observed to occur except during the actual progress of 
primary dentition ; and where it does not terminate fatally, at an 
earlier period, it always subsides soon after the completion of this 
process. 

Treatment. — The chief indications to be attended to in the treat- 
ment of the affections under consideration, are : to obviate the influ- 
ence of the remote irritating cause ; to allay the nervous or cerebral 
irritation upon which the convulsive phenomena immediately de- 
pend ; and to protect the brain from too powerful a determination 
of blood to, and congestion of, its vessels. 

Where there is reason to believe, from the swollen and irritated 
state of the gums, the dental irritation is the exciting or accessory 
cause of the convulsive attack, the gums should be divided down to 
the advancing tooth. This measure is particularly important in the 
" carpo-pedal" form of convulsions, mentioned above ; as it appears 
invariably to be a consequence of irritation from this source. If, on 
the other hand, it should appear that gastro-intestinal irritation is 
the exciting cause of the disease, whether from crude or indigestible 
ingesta. acrid secretions, or worms, immediate steps should be taken 
to remove the offending cause. If the child has received any unu- 
sual food, of difficult digestion, into the stomach, a few hours before 
the occurrence of the convulsions, it will be proper to administer a 



CONVULSIVE AFFECTIONS OF INFANTS. 99 

full dose of ipeoacuanha, with the view of exciting free vomiting.* 
Before resorting to this remedy, however, it is necessary to apply 
the means, presently to be mentioned, calculated to derive the circu- 
lation from the head, and to protect the brain from the effects of 
strong vascular engorgement. I have lately seen an instance of vio- 
lent convulsions, which continued until spontaneous vomiting brought 
off a large quantity of raisins, with which the child had been suffered 
to gorge its stomach. To remove the irritating matters that, may be 
lodged in the bowels, purgative enemata, and if the child can be 
induced to swallow, infusion of senna and spigelia may be advan- 
tageously resorted to. In all instances, indeed, purgative injections 
are appropriate, on account of their revulsive tendency ; and what- 
ever other measures are adopted, these, if the necessary means are 
at hand, should not be neglected. 

Blood-letting, though not always applicable, is, in some instances 
a very important auxiliary in the management of these affections. 
A principal object in the treatment of convulsions, is to protect the 
brain from fatal oppression ; and for this purpose bleeding is one of 
our most efficient means. Where the signs of strong determination 
to the head are manifest, and especially in robust and plethoric chil- 
dren, blood should be promptly abstracted. On the contrary, however, 
it will be prudent to abstain from this evacuation in patients of a 
weak and relaxed habit, and where the ordinary evidences of vascular 
engorgement are absent. With regard to local bleeding, by leeches 
to the head, my own experience accords entirely with the following 
observations of Dr. North. " I have never seen well marked symp- 
toms of determination to the head in children removed by leeches, 
however freely they were applied. Their application never fails to 
annoy the little patient considerably, and their effect is not to be 
relied on." If it be deemed necessary to draw blood directly from 
the vessels of the head, this writer recommends bleeding from the 
jugular vein, or by cupping upon the temples or behind the ears. In 
cases where the little patient sinks into a state of coma, with flushed 
countenance, throbbing of the carotids, &c, after an attack of convul- 
sion, local depletion, in any of these latter modes, is sometimes indis- 
pensable to the safety of the patient's life. 

Some practitioners are in the habit of giving large and repeated 
doses of calomel, in the convulsions of infants, under an idea that 
there is something peculiarly beneficial in the operation of this article 
in affections of this kind. Dr. North objects strongly to this practice, 
as tending in no small degree to injure the constitutions of children. 
That calomel is too heedlessly and indiscriminately given in -the affec- 
tions of children, particularly in the United States, I have not the 
smallest doubt. I am quite certain that I have seen instances where 

* [This is by far the most important indication to fulfil, and should never be 
neglected. I attended a little boy a few weeks ago who had fallen into frightful 
convulsions, after undergoing a surgical operation, and when every other reme- 
dy had failed, the rejection of a piece of orange peel he had taken many hours 
before, was followed by immediate relief. — Mc] 



100 CONVULSIVE AFFECTIONS OF INFANTS. 

this practice was the cause of great and irreparable constitutional injury. 
Nevertheless, it has appeared to me, that one or two active doses of 
this article, so as to cause free alvine evacuations, is capable of pro- 
curing more advantage, in general, in the convulsions of infants, 
than any of the other usual means for evacuating the alimentary 
canal. 

Revulsive applications, with the view of equalizing the nervous 
excitement, and deriving the circulation from the encephalon, are 
always proper, and often promptly sufficient in moderating or arrest- 
ing the convulsions. Warm pediluvium, the water being as warm 
as can be borne without injuring the skin, is one of the most bene- 
ficial of this class of remedies. This measure is particularly apt to 
afford relief in convulsions excited by the irritation of dentition. The 
good effects of very warm applications to the feet are much enhanced 
by cold applications to the head. While the feet and legs are im- 
mersed in warm water, a piece of flannel, wet with cold water, should 
be applied over the head and temples. These measures are especially 
important in cases attended with symptoms of sanguineous congestion 
in the head, and cannot be omitted without losing one of our most 
efficient remedies in such affections. Not unfrequently, these appli- 
cations are alone sufficient to put a speedy termination to sympathetic 
convulsions. Where the determination to the head is very great and 
persistent, it will be proper to apply pounded ice in a bladder to the 
scalp, while applications of warm water or sinapisms are made to 
the feet. Some writers recommend putting the patient into a warm 
bath, while the cold applications are made to the head ; but I suspect 
that, at most, warm semicupium will in general exert a better revul- 
sive effect than immersion of the whole body. Dr. North observes, 
that for many years he has "directed the practice of immersing the 
child's lower extremities in a warm bath; while cold water is poured, 
in a gentle stream, on the head of the cervical spine." While these 
applications are being made " the countenance and pulse should be 
attentively watched. When paleness and collapse of the face su- 
pervene, and the pulse declines or intermits, the cold applications 
should be suspended, and the head and trunk covered with a dry 
cloth ; but as soon as signs of reaction return, the process is to be 
resumed even to the third or fourth time, till its good effects shall be 
decisive and manifest in the suppression of all convulsive motions." 
(North.) 

The operation of blisters is in general too slow to admit of useful 
applications in the ordinary cases of infantile convulsions. Never- 
theless, where there is reason to apprehend a repetition of the attacks, 
small blisters laid behind the ears, or on the back of the neck, are in 
general decidedly beneficial. Vesication on this part is particularly 
calculated to afford advantage in those cases which supervene on the 
drying up of superficial and discharging ulcerations behind the ears. 
Some benefit may also be expected from the application of blisters 
to the inferior extremities, as counter-irritants. Dr. North, whose 
authority upon this subject deserves much respect, says " that in 
many instances where there was evident determination to the head, 



CONVULSIVE AFFECTIONS OF INFANTS. 101 

without any general excitement, he has obtained the best effects 
from blisters to the calves of the legs, or between the shoulders." 
The application of blisters to the head, in any of the inflammatory or 
congestive affections of the brain, is very rarely attended with advan- 
tage ; and in many cases appears rather to augment than relieve the 
evil. In hydrocephalus, I have never known even the slightest tempo- 
rary advantage from vesication of the scalp. It is, nevertheless, not im- 
probable, that in sympathetic convulsions, some benefit might accrue 
from counter-irritation on the scalp ; though my experience furnishes 
me with no facts in confirmation of the usefulness of this practice. 

Rubefacient frictions along the course of the spine, is a practice I 
resort to in most instances of protracted convulsions, and in some 
cases manifest benefit appeared to me to result from it. When the 
convulsions assume a tetanic character — the body remaining for some 
time rigidly bent backward— leeching, and sinapisms over the spinal 
region would seem to be more especially indicated. 

Formerly, physicians were much in the habit of exhibiting anti- 
spasmodics in infantile convulsions— such as assafetida, camphor, 
valerian, musk, and ol. succine. In children of a very nervous or 
irritable habit, some benefit may occasionally be derived, during the 
fit, from assafetida, musk, or the oil of amber, provided no signs of 
determination to the head be present. Upon the whole, however, 
these are, under the most favourable circumstances, of very equivo- 
cal propriety; and they are decidedly improper, where the arterial 
reaction is considerable, and the vessels of the head engorged. 
Opium is a remedy that may either do very serious mischief, or no 
small degree of good, according to the particular states of the system 
and the character of the attending circumstances of the case. In 
instances attended with cerebral erethism, or encephalic vascular con- 
gestion, nothing perhaps would be more likely to do harm than opium, 
more especially in robust and full habits. In general, it may be said, 
that whatever local or general depletion is indicated, opiates are to be 
avoided. On the contrary, however, where convulsions arise sym- 
pathetically, in consequence of some remote and fixed irritation; as 
in the alimentary canal, and the habit of the patient is irritable, re- 
laxed and feeble, opium, judiciously administered, may afford decided 
benefit. It is, indeed, anceps remedium, but the practitioner who 
has learned to discriminate between the circumstances that indicate 
or contra-indicate the propriety of its use, will often find it a most 
valuable auxiliary. In general, it is altogether inadmissible in con- 
vulsions arising from the irritation of dentition; and in cases depending 
on causes seated within the head, it is, if possible, still more inappro- 
priate. When the primary irritation is located in the alimentary 
canal, we may, under the other favourable circumstances just men- 
tioned, employ small doses of Dover's powder, repeated according to 
the exigencies of the case, with manifest advantage. Opiate embro- 
cations over the chest and spinal region will also, in such cases, afford 
benefit. These are particularly useful where, from great nervous 
irritability, there is a strong tendency to convulsive attacks, unaccom- 
panied with general vascular irritation. 



102 IITSTERIA. 



When convulsions arise from repelled chronic cutaneous affections, 
we must endeavour to prevent their recurrence by the use of the warm 
bath, frequently dry frictions, and sulphur given internally. Setons 
and issues may also aid us in such cases. 

The treatment proper in the carpo-pedal form of convulsions, 
embraces the employment of general and local bleeding; laxatives; 
small doses of calomel, to correct the functions of the liver; cold 
applications to the head; rubefacient and anodyne embrocations along 
the track of the spine; warm bath and pediluvium; a strict attention 
to the state of the gums; and the avoidance of every thing calculated 
to cause unusual excitement of the system. 



Sect. VII. — Hysteria. 

In relation to the diversity and variableness of its phenomena, 
hysteria is truly a "protean disease." It is essentially a dynamic 
affection of the nervous system, manifesting itself by morbid phe- 
nomena in every sensitive and irritable part of the system, in the 
voluntary and involuntary muscular systems, in the sensorial organs, 
the brain, the intellectual faculties, the digestive apparatus, the various 
glandular viscera; in short, it presents, in its multifarious symptoms, 
every morbid sympathy, perhaps, of which the animal system is sus- 
ceptible. 

Hysteria may be divided into three modifications, namely, 1, chro- 
nic or habitual hysteria ; 2, paroxysmal or convulsive hysteria; 
and 3, hysteric insensibility or stupor, without spasms of the volun- 
tary muscles. 

1. Chronic or habitual hysteria occurs in weak, delicate and irri- 
table habits, particularly in such as are affected with profuse leucor- 
rhoea, or suffer frequent menorrhagic discharges. Females affected 
with this form of the disease are usually called nervous. They are 
almost always complaining of some unpleasant or painful sensations; 
their temper is variable, often fretful, sometimes animated, talkative, 
and anon peevish and gloomy; they pass often rapidly from laughing 
to crying, from gayety to melancholy, from despondency to hope, 
and vice versa, from the most trifling causes. They often complain 
of various distressing sensations in the abdomen, head or chest. 
Flatulency, a rumbling noise in the bowels, severe colic pains, a sense 
of weight and bearing down in the region of the uterus, pain in the 
neck of the bladder, dysury, a feeling of emptiness, or of fullness 
and tension in the pit of the stomach, variable appetite, slow diges- 
tion, eructations, occasional spells of great anxiety and alarm, palpi- 
tation, weakness and syncope, or a sense of sinking in the praecordia, 
ringing in the ears, confusion of mind, transient pains in the various 
parts of the body, and the sensation of a ball rising in the throat to 
the top of the sternum, causing oppressed and hurried respiration, and 
a feeling of impending suffocation, (globus hystericus,) are among 
the most common symptoms of this modification of the disease. A 
peculiar numbness, or feeling as if insects were creeping on the top 



HYSTERIA. 103 

of the head, is sometimes experienced ; and a violent circumscribed 
pain, often not above an inch in circumference, is a frequent affection 
in this form of the disease. Many females affected with chronic 
hysteria frequently experience a troublesome pain confined to a 
small space just below the left breast; and others suffer much incon- 
venience from a deap-seated circumscribed pain in the left iliac 
region. 

Patients labouring under this form of constitutional hysteria seldom 
become affected with convulsions. The ordinary exciting causes 
of the hysteric paroxysm are much more apt to produce in them 
syncope, insensibility, or temporary mental derangement, or spasmo- 
dic and very painful affections of the alimentary canal, dyspnoea, and 
globus hystericus, than distinct convulsions. 

2. The hysteric paroxysm usually comes on suddenly. Sometimes 
the fit consists in violent and convulsive laughing, alternating with 
crying and screaming; or attended with mental alienation; rapid and 
incoherent talking; singing; suffocative spasms of the throat; a wild 
and furious expression of the countenance ; raving ; gnashing the 
teeth ; tearing out the hair; beating the breast with the hands ; biting, 
&c. Occasionally these symptoms subside without terminating in 
convulsions. More commonly, however, convulsions, of terrific vio- 
lence, speedily supervene. The spasms usually partake more of the 
tonic or tetanic character, than of the clonic or strictly convulsive 
form. The body is rigidly bent backwards, or variously and most 
powerfully contorted ; the breast projected forwards, and the head 
drawn backwards; the face swollen; the tongue protruded, or the 
jaws firmly closed ; the eyes rolling, prominent and red ; the teeth 
gnashed; the fists clenched ; the arms spasmodically thrown about, 
and the abdominal muscles violently contracted; in short, the whole 
muscular system is thrown into such violent spasms, that scarcely 
any attempt of the bystanders is sufficient to restrain the contortions, 
or prevent the patient from being thrown out of bed. When the 
paroxysm ceases, the patient is left in an exhausted, and stupid or 
somnolent condition, which in the course of an hour or two passes 
off, without leaving any other affections than a feeling of general 
soreness, and a slight pain or uneasiness in the head and pit. of the 
stomach. This form of hysteria does not often occur in very weak 
and delicate individuals, habitually labouring under the former variety 
of hysteric symptoms. It is more commonly met with in sanguine- 
ous, plethoric, and robust females, of strong passions; and occurs 
usually as the immediate consequence of some disagreeable mental 
emotion, or the sudden suppression of the catamenial discharge. 

In plethoric and irritable habits the hysteric attack occasionally 
seizes chiefly on the heart and arteries, giving rise to what the older 
pathologists called turgescentia nervosa* The face becomes flushed 
and turgid ; the heart palpitates violently; the pulse beats tumultu- 
ously ; the carotids throb ; the patient complains of headache, becomes 
slightly delirious, and often experiences transient pains in the side, 
with hurried and anxious respiration. 

* Richter, loc. cit., vol. vii. p. 445. 



104 HYSTERIA. 

In some instances, the paroxysm assumes the phenomena of vio- 
lent asthma, with a highly excited state of the vascular system. 
Sometimes the disease assumes the form of severe cholera, with 
extreme gastric pain, and continued retching or vomiting. 

3. In some instances, the patient, without any previous spasmodic 
affections, sinks into a state of complete insensibility. She lies on 
her back, with the extremities extended and relaxed, the eyes closed, 
the teeth firmly locked, and the breathing slow and intermitting, but 
without being laborious or audible ; the pulse is generally regular, 
slow, and small ; the countenance natural or pallid; the extremities 
cool; and the sensorial functions and power of swallowing appear 
to be entirely suspended. Occasionally a deep and long inspiration 
is made ; and the patient is apt, when some degree of sensibility 
returns, to tear the clothes from her bosom, or to press upon it with 
both her hands. Sometimes young females will continue in this 
state for many hours. I have known it to last a whole day ; at others 
the paroxysm is transient. It generally passes off rather suddenly. 
The patient awakes, as it were, from a deep sleep, suddenly raises 
herself into a sitting posture, looks about with an air of surprise, and 
speedily recovers the entire possession of her mental and corporeal 
powers. During this state of hysteric stupor, the urine is almost 
always retained, or perhaps suppressed, and soon after its subsidence 
a large quantity of a pale or watery appearance is commonly dis- 
charged. 

This modification of the hysteric paroxysm is most apt to occur in 
young unmarried females, from sudden suppression of the menses, 
or a consequence of violent mental emotions — and perhaps still more 
commonly from taking heavy and indigestible food during the cata- 
menial period. 

Pathology. — Hysteria, though not exclusively, is chiefly confined 
to females. It never occurs during childhood, and its appearance in 
the form of convulsions or distinct paroxysms in old age, is almost 
equally uncommon. The range of its sway is almost entirely con- 
fined to the period which intervenes between the commencement 
and the complete cessation of the uterine functions. It. is particu- 
larly apt to occur, in its less violent forms, at the latter critical epoch 
of female life ; and paroxysmal or convulsive hysteria occurs often 
shortly before and after the first appearance of the catamenia. 

There is, therefore, something peculiar in the female organization, 
which renders them so especially the subjects of this remarkable, affec- 
tion ; something, we may presume, distinct from mere delicacy of 
structure and nervous irritability; for, although men of nervous tem- 
perament and weak and irritable habits may occasionally surfer 
some of the lighter symptoms of hysteria, they very rarely, if ever, 
so far as I know, become affected with the true hysteric paroxysm! 
Let us advert then to the circumstance, that the susceptibility for this 
disease commences only with the development of the proper uterine 
or sexual functions, and again diminishes, and finally ceases with 
the entire cessation of these functions— that, in short, the period of 
life during which the uterus maintains its influence 'or sympathies 



HYSTERIA. 105 

in the female system, is that period also to which the occurrence of 
hysteria is almost exclusively confined, and we are led to the con- 
clusion, that, in some way or other, the female generative organs 
have an intimate concern in the production of this affection. 

From these and other analogous circumstances, it has been inferred 
that the proximate cause of hysteria is located in the uterus — a doc- 
trine which is indeed expressly implied in the name g^ven to this 
affection. Hippocrates, Zacutus Lusitanus, Fr. Hoffman,* Rave, 
Salmuth, and more recently Villermay, entertained this view of the 
pathology of hysteria ; and Richter observes, that the generative 
system is « very frequently" the point whence the morbid sympa- 
thies, which give rise to the hysteric phenomena, radiate ; and that 
in such cases, the disease may, in certain respects, be regarded as 
proceeding from the sexual organs.! 

The general opinion at present, however, is that the brain, and 
not the uterus, is the essential seat of hysteria ; and there can be no 
doubt, indeed, that the convulsive form at least, as well as many 
other morbid phenomena manifested by the disease, are directly 
dependent on cerebral irritation. It appears, nevertheless, highly 
probable, also, that many symptoms belonging to this affection are 
the immediate result of an irritation located in the ganglionic system 
of nerves, exclusive, perhaps, of any direct dependency on cerebral 
reaction. Hysteria is emphatically a nervous affection. Its funda- 
mental condition would appear to consist in an extremely sensitive 
and excitable state of the whole nervous system, and a consequent 
inordinate activity of the various organic sympathies. We may pre- 
sume, that if, in a system thus constituted, an irritation occurs in any 
part of the body, it will be rapidly transferred, either to the organs 
which maintain the closest sympathetic relation with the part pri- 
marily irritated, and give rise in them to local pain, or spasm, or 
uneasiness ; or to the brain, causing disturbance of the intellectual 
or sensorial functions, and being thence reflected upon the muscles 
and other parts, exciting spasms, pain, and convulsions. 

Mr. Tate, in a small work on hysteria lately published, endeavours^ 
to prove that the proximate irritation on which the phenomena of 
hysteria depend, is located in the spinal marrow. He asserts, that 
in the majority of cases of this disease, whether of a paroxysmal 
or chronic character, considerable tenderness will be found to exist 
in some part of the spinal column, and in some cases, the soreness 
to pressure is very great. The application of a tartar emetic plaster 
over the part of the spine which is morbidly tender, very rarely fails, 
he says, to remove the disease, however violent it may be, or long it 
may have continued.^ 

Causes.— The predisposition to hysteria depends sometimes on a 
peculiar constitutional habit, and in some instances, is manifestly 
hereditary. Girls of a delicate and relaxed habit of body, light hair, 

* Med. Rationel. Systema., torn, iv, p. 161. 
t Specielle Therapie, bd. vii, p. 451. 

% A Treatise on Hysteria, &c, &c. By George Tate, Surgeon, &c. London, 
1831. 



106 HYSTERIA. 

blue eyes, a fair skin, and sanguineous habit, with precocious intel- 
lect, animated dispositions, lively fancy, and early sexual develop- 
ment, are in general most liable to hysteric affections in after-life. 
Very generally, however, the predisposition to hysteria is acquired 
from the influence of causes that tend to produce plethora, nervous 
irritability, and general relaxation. This affection is, comparatively 
speaking, not often met with in individuals inured to an active or 
laborious course of life, or accustomed to a plain and regular mode 
of living. Like gout, it is much more commonly encountered in the 
mansions of the rich and luxurious than in the hovels of the poor 
and laborious. Indolence, sedentary habits, a pampered and luxu- 
rious mode of living, the too early and overstrained exercise of the 
mind, the habitual excitement of the imagination, and of the moral 
sympathies, by the perusal of high-wrought descriptions of affecting 
incidents, or of circumstances calculated to awaken and keep alive 
agitating emotions, are among the most common and influential 
causes of the nervous or hysteric predisposition. The depressing 
passions also have a powerful tendency to predispose to, as well as 
to excite, hysteric affections. 

The exciting causes of hysteria are exceedingly various. They 
may, however, be arranged under the following heads:* 

1. Those ivhich act immediately upon the sensorium commune. 
— Violent anger, terror, grief, jealousy, remorse, envy, disappointed 
ambition, prostrated hope, hatred, loss of reputation, unfortunate 
love, mortified pride, opposed desires, in short, whatever strongly 
agitates or affects the mind, may excite hysteric symptoms. Under 
this head we must also place the production of the disease by the 
sight of persons labouring under the hysteric paroxysm. Osiander 
relates some very remarkable instances of this kind;t and cases ex- 
cited in this way are mentioned by Tissot,J Whytt, Rowley,§ Reil, 
and others. 

2. Disagreeable impressions on the organs of sense, depending 
generally upon idiosyncrasy. — Richter states, that acute and melt- 
ing tones, particularly those produced by the harmo?iica, have 
often suddenly excited hysteric affections. Disagreeable odours, also, 
sometimes produce this effect ; and the same consequence has been 
known to result from certain impressions received through the sense 
of touch. 

3. Irritating substances lodged within the alimentary canal— 
In persons predisposed to hysteria, indigestible and irritating articles 
of food are particularly apt to excite hysteric affections. This is one 
of the most abundant sources of those habitual hysterical complaints 
so frequently met with in females of nervous temperaments and weak 
digestive powers. Intestinal irritation from wind, acrid secretions, 
or worms, may also give rise to this affection. 

* Richter. loc. cit., bd. vii, p. 456. 

t Entwickelungs Krankheiten, vol. i. 

+ On the Diseases of the Nervous System, vol. ii. 

h On the Diseases of Females. 



HYSTEBIA. 107 

4 Suppressed evacuations. — The sudden suppression of the eata- 
menial discharge during its flow, often gives rise to extremely violent 
paroxysms of hysteria. The remote cause, in instances of this kind, 
is usually cold — particularly the application of cold to the feet while 
the menses are flowing, or just about making their appearance. Au- 
thors mention, also, suppressed perspiration and hemorrhoidal dis- 
charge among the exciting causes of this disease; and repelled chronic 
cutaneous eruptions arc said, occasionally, to give rise to hysteric 
affections. 

5. Excessive evacuations. — Inordinate sanguineous or serous 
discharges may, perhaps, more frequently act as predisposing than 
exciting causes of hysteria. Ee this as it may, it is certain that 
females who are affected with profuse leucorrhcea, or frequent me- 
norrhagia, are peculiarly liable to hysteric complaints. Excessive 
hamiorrhoidal evacuations, chronic diarrhoea, profuse lochia, and 
nursing infants too long at the breast, appear to be particularly fa- 
vourable to the occurrence of various nervous affections. 

6. Causes that tend to augment the sensibility and to produce 
an habitual erethism of the sexual organs, have, without doubt, a 
powerful influence in the production of hysteria.* The frequent 
excitation of voluptuous feelings by improper reading, conversation, 
pictures, or the workings of an unchastened and active imagination, 
&c.,are,I apprehend, not unfrequently deeply concerned in the causa- 
tion of this affection. Where the sexual propensity is early deve- 
loped, and supported by influences of this kind, and its gratification 
firmly resisted by moral restraints, or unsatisfied from less praise- 
worthy motives, hysteric paroxysms are particularly apt to occur. 
Hence, perhaps, the occasional removal of the hysteric diathesis in 
young females by marriage. 

Diagnosis. — Many eminent pathologists have regarded hysteria 
and hypochondriasis as essentially the same affection. t The general 
opinion at present, however, is that they are distinct diseases; and 
this is unquestionably the correct view of the case. The following 
are the prominent distinguishing characters of these affections: 

1. Hysteria occurs chiefly in individuals of nervous, irritable, and 
plethoric habits, of great mental and corporeal excitability, quick 
perception, rapid transitions of disposition and temper. Hypochon- 
driasis, on the other hand, very generally attacks persons of sluggish, 
melancholic temperaments, unirritable fibre, addicted to deep and 
fixed reflection, musing, and reverie. 

2. Hypochondriasis is not so variable in its phenomena, and more 
protracted in its course, with less manifest remissions and exacerba- 
tions than hysteria. 

3. Hysteria generally comes on and goes off suddenly, and is at- 
tended with an increased excitability of the nervous system, and 
with various painful and spasmodic affections. Hypochondriasis 

* Richter, loc. cit., bd. vii, p. 460. 

f Stahl, Sydenham, Whytt, Tissot, Van Swieten. Sellc, K. Sprengel, Henke ; 
and Zimmerman, were of this opinion. 



108 HYSTERIA. 

almost always approaches slowly, without spasm or distinct pain, 
and gradually increases in violence, and again goes off in the same 
gradual manner. 

4. In hypochondriasis, the primary irritation is much more distinctly 
seated in the abdominal viscera; the digestive and hepatic functions 
are more prominently and permanently affected than in hysteria. 

5. In hypochondriasis the mind is, as it were, paralyzed— fixed with 
steadfastness upon some engrossing subject. In hysteria the intellec- 
tual powers are versatile ; often active, and sometimes wildly confused. 
Hysterical patients experience more corporeal sufferings ; hypochon- 
driacs more of mental distress. The former are more occupied with 
present complaints ; the latter look into futurity with distressing and 
gloomy forebodings of distant evil. The hypochondriac feels himself 
an insulated, deserted and doomed being— loses his sympathies for 
the world — even his natural propensities and passions are absorbed 
by the ruling idea. The hysteric patient, on the contrary, is often 
agitated by various emotions and feelings; he loves, hates, cries, laughs, 
hopes, fears, is garrulous or taciturn, in rapid succession, and often 
apparently without any adequate causes. 

Treatment. — Treatment proper in convulsive or paroxysmal 
hysteria. — The principal indications in the treatment of hysteric con- 
vulsions, are: — 1. To obviate inordinate sanguineous congestion in 
the head, by depletory and revulsive applications; 2, to allay the 
morbid excitement in the nervous system, by anodyne and antispas- 
modic remedies ; and 3, to remove, as much as may be in our power, 
the local irritating causes, upon which the irregular determinations 
and morbid actions both of the nervous and sanguiferous systems 
depend. 

It has already been observed, that strong sanguiferous determina- 
tion to the head perhaps always occurs in the hysteric paroxysm. 
The suffused and turgid face, projecting and blood-shot eyes, disten- 
sion of the jugulars, and throbbing of the carotid and temporal arteries, 
so generally noticed during a fit of hysteric convulsions, are sufficient 
evidences of a highly congested state of the encephalon. If, in addi- 
tion to the signs of inordinate sanguineous determination to the head 
just mentioned, the pulse be active, full or tense, or the general habit 
of the patient manifestly plethoric, bleeding to an extent sufficient to 
make an evident impression on the pulse should be immediately prac- 
tised. This is not only a proper precautionary measure for obviating 
any serious consequences that may result from the strong vascular 
turgescence within the head, but it is also decidedly beneficial as a 
preparatory step to the employment of other remedies.* This evacu- 
ation is especially useful in cases that occur in young and sanguine- 
ous females, from the sudden suppression of the catamenial discharge. 
In instances of this kind an efficient blood- letting rarely fails to 
moderate the symptoms very speedily, and occasionally, to induce a 
complete intermission of the spasmodic actions. With the view of 
equalizing the circulation and nervous excitement, sinapisms to the 

* Dr. Dewees, Treatise on the Diseases of Females, p. 486. 



HYSTERIA. 109 

inferior extremities, or, if practicable, warm pediluvia mav also be 
very beneficially applied. 

In prescribing internal remedies in the hysteric paroxysm, it is of 
much consequence to pay particular attention to the nature of the 
exciting cause. When the paroxysm is the immediate consequence 
of gastric irritation from indigestible or irritating articles of food, an 
emetic should be immediately administered, and vomiting excited as 
speedily as possible.* I have frequently administered the sulphate 
of zinc in such cases with the happiest effect. The usual antispas- 
modics will do little or no good in instances arising from causes of 
this kind ; and it is therefore particularly necessary, on being called to 
such cases, to inquire into the nature of the ingesta or diet taken pre- 
vious to the occurrence of the paroxysm. In some instances depending 
on gastric irritation, the convulsions alternate with violent retching, 
attended usually with excruciating pains in the stomach. When this 
happens, vomiting should be encouraged by copious draughts of tepid 
water, or by moderate doses of ipecacuanha. As soon as the offending 
contents of the stomach are entirely thrown off", a full dose of lauda- 
num should be administered, provided no symptoms of strong cephalic 
congestion be present. 

When the hysteric paroxysm is excited by mental emotions, narco- 
tic and antispasmodic remedies are appropriate means. Laudanum, 
assafcetida, musk, sulphuric ether and castor, may be employed for this 
purpose. Laudanum is particularly valuable in hysteric affections 
resulting from moral causes. It may be given by itself, or, perhaps, 
more advantageously, in union with ether or assafetida, according to 
the following formula.t 

It is sometimes impossible to introduce any medicines into the sto- 
mach during the hysteric paroxysm. When this is the case, antispas- 
modic and anodyne enemata ought to be resorted to. From twenty 
to thirty grains of assafetida, dissolved in six or eight ounces of water, 
with the addition of a teaspoonful of laudanum, may be thrown into 
the rectum. 

In those violent paroxysms of hysteria which sometimes occur in 
consequence of the menses becoming suddenly arrested during their 

* [This is, according to my experience, the most common exciting cause of the 
hysteric paroxysm. At all events I always begin with the administration of large 
quantities of warm water, and if that does not excite vomiting, I give mustard 
infusions. In cases where the mouth is spasmodically closed, I bind the limbs 
with strong ligatures for a few minutes, and seize the first opportunity to force 
down an emetic. As long as the stomach continues to be oppressed by undigested 
matters, it will prove impossible to relieve by the use of antispasmodics or stimuli. 
— Ma] 

t K. — Tinct. opii gss. 

.(Ether sulph. £ii. — M. S. From 40 to 80 drops, and repeated accord- 
ing to its effects on the system. 

R. — Tinct. opii ^ii. 

assafcetid. §i. — M. S. A dessert spoonful every half hour until the 

symptoms are moderated. 



110 HYSTERIA. 

flow, from the application of cold to the feet, bleeding, sinapisms to 
the ankles, warm pedilnvia, and particularly turpentine enemata, 
with the internal use of assafetida, are particularly applicable. In 
an extremely violent case of this kind, in a young and unmarried 
woman, I lately administered about half an ounce of the tincture of 
secale cornutum, with prompt and very decided benefit. In ten 
minutes after this article was swallowed, the convulsive symptoms 
were entirely allayed. In very obstinate and protracted instances of 
this character, I have known great advantage to result from turpen- 
tine injections.* 

My usual practice has been to repeat the terebinthinate injections 
until the bowels are well evacuated; and, when this is effected, to 
throw about two drachms of turpentine, mixed with a drachm of 
laudanum and a small portion of milk, into the rectum. 

When the hysteric paroxysm precedes the eruption of the menses, 
camphor, or camphor with opium, is, according to the experience of 
Dr. Dewees, the most efficient remedy. He recommends the follow- 
ing mixture for this purposet — a mixture which I have myself em- 
ployed with much advantage in such cases. Here also warm pedi- 
luvia, rubefacient frictions to the inner part of the thighs, warm 
bricks wrapped in dry flannel and applied to the pelvis, turpentine 
enemata, and cold applications to the head, are particularly indicated. 

In that variety of paroxysmal hysteria in which the patient lies in 
a state of torpor and insensibility distinct from syncope, I know of 
no remedy so effectual for dispelling the attack as an emetic. If a 
full dose of ipecacuanha, or of the sulphate of zinc, can be introduced 
into the stomach and vomiting excited, complete recovery will gene- 
rally speedily ensue. I have known patients, after having lain for 
several hours in a state of insensibility, awaken as from a sleep, sit 
up and converse rationally almost immediately after vomiting was 
excited by an emetic. In cases of this kind, prompt relief may also 
sometimes be obtained from a large sinapism to the epigastrium. In 
a case which I lately attended, where vomiting could not be excited, 
although several full doses of ipecacuanha and sulphate of zinc were 
introduced into the stomach, I directed a strong sinapism to be ap- 
plied over the whole epigastrium. In less than twenty minutes she 
suddenly raised herself, looked about with an air of surprise, and 
immediately began to vomit, which had the effect of soon removing 
every symptom of the complaint. Antispasmodic enemata, too, may 
be very beneficially employed in such cases — and for this purpose 

* R.— 01. terebinth, jfiss. 

Vitelli ovi. 

Solut. gum. Arab. ^viii. — M. 
t B- — G. camph. ^ii. 

Spir. vin. rect. q. s. f. pulv. adde, 

Pulv. G. Arab. giii. 

Tinct. thebaic, acetat. gtt. lx. 

Sacch. albi 3iii. 

Aq. fontanae !§vi.— M. Dose, a tablespoonful every hour or two. 



HYSTERIA. Ill 

nothing perhaps is so effectual as an aqueous solution of assafetida. 
Opium and the more diffusive stimulants do not appear to answer 
well in instances of this kind. Much benefit may, however, be 
occasionally obtained by stimulating the olfactory nerves with am- 
monia, or the fumes of a burned feather. 

Besides the remedies already mentioned, a variety of other means 
may be employed with occasional success in the hysteric paroxysm. 
The injection of very cold water into the rectum will sometimes 
promptly allay the hysteric paroxysm. Riverius speaks particularly 
in favour of the injection of cold water and vinegar ; and Darwin used 
ice-water with marked success. Great benefit may also, at times, be 
obtained from injections of a decoction of ipecacuanha, in the propor- 
tion of two drachms of the root to eight ounces of water. 

Dr. Dewees considers the so common practice of exciting the olfac- 
tory nerves by stimulating volatiles, as of very doubtful propriety. 
In plethoric habits, and where there is much sanguineous determina- 
tion to the brain, the impropriety of this practice appears, indeed, very 
obvious. Richter observes, that applications of this kind are equally 
apt to prove injurious in cases attended with great general nervous 
excitability. There exist, moreover, in many individuals subject to 
hysteric affections, very extraordinary idiosyncrasies in relation to 
particular odours. Some patients will be very disagreeably or injuri- 
ously affected by certain articles of this kind, yet greatly tranquilized, 
or beneficially excited by others. 

Richter mentions the case of a lady who was always readily roused 
from hysteric stupor or syncope, by the smell of old and rank cheese. 
I know an hysteric female in this city, who is invariably very disa- 
greeably affected by the smell of hartshorn, but the fumes of burning 
feathers rarely fail to produce beneficial effects. In some instances, 
the smell of strong vinegar does more good than the more volatile 
and pungent articles usually employed for this purpose.— (Richter.) 
The smell of garlic bruised and moistened with vinegar, occasionally 
produces a very prompt and beneficial effect. We may sometimes 
suddenly arrest the lighter hysteric paroxysms by exciting some 
sudden emotion, as of anger, in the mind of the patient. 

What I have hitherto said refers chiefly to convulsive paroxysms 
of hysteria. The most unmanageable and troublesome cases of this 
disease, however, are those chronic instances of hysteria usually de- 
nominated nervous affections, and which, though seldom marked by 
violent paroxysms, are nevertheless attended with frequent, and gene- 
rally distressing nervous symptoms. As palliatives, the antispasmo- 
dics and narcotics already mentioned are very much employed in this 
modification of the disease. In general, assafetida gives more per- 
fect and prompt relief than any other article of this kind. Some 
patients, however, derive much more benefit from other antispasmo- 
dics Indeed, there exists the utmost diversity with regard to the 
degree of relief obtained by different individuals from remedies of 
this kind. A mixture of sulphuric ether and laudanum* constitutes, 

# jj . — Sulph. aether gss. 

Tinct. opii 3ii.— M. Take 30 drops every two hours till relieved. 



112 HYSTERIA. 

with most patients, an excellent antispasmodic. Opium is, in truth, 
a most soothing remedy in chronic nervous affections. It allays the 
inordinate excitability of the nervous system; subdues for a time all 
unpleasant sensations and morbid sympathies; and diffuses a delight- 
ful feeling of tranquillity throughout the whole organization. Could 
these effects be enjoyed without the risk of contracting a habit for 
taking this oblivious drug, opium would, indeed, be to patients of this 
kind the magnum donum del Let no nervous person, however, 
resort frequently to this medicine. It will come at first like an angel, 
with its balmy powers, to dispel pain, lowness of spirits, and mental 
disquietude of every kind; it will bring hilarity and pleasantness of 
feeling when its aid is first invoked ; but it will not fail ultimately to 
insinuate itself into every fibre, and to cause indescribable wretched- 
ness and suffering to the unfortunate victim. In many individuals, 
the ordinary preparations of opium, particularly la udanum, produce 
very disagreeable effects. Where such an idiosyncrasy exists, and 
the indications are favourable to the employment of this narcotic, the 
acetated tincture of opium may, in general, be used without any un- 
pleasant consequences whatever. Some patients, who cannot take 
laudanum without very distressing effects, will feel no inconvenience 
from it if it be given with eight or ten grains of the carbonate of 
potash. 

Castor, with some individuals, is peculiarly beneficial as a pallia- 
tive. I have frequently known this article to procure much relief 
after the more active antispasmodics had been ineffectually used. It 
seems to be particularly calculated to do good when the disease is 
attended with much uneasiness and flatulent pains in the lower part 
of the abdomen. Some persons, on the contrary, cannot take this 
medicine without unpleasant consequences. I have usually em- 
ployed the castor in combination with other articles of similar 
powers, according to the following formula.* 

In cases attended with much debility of the digestive organs, vale- 
rian often produces very excellent effects. From its gently tonic 
powers, it is, indeed, peculiarly suited to such cases. The ethereal 
tincture is an excellent preparation for this purpose.t An aqueous 
infusion, also, with the addition of 10 or 15 drops of the liquor am- 
nion, succinata to each dose, or of four or five grains of supercarbo- 
nate of soda, generally answers very well. 

The root of the pathos foetida (skunk cabbage), will occasionally 

* .R — Tinct. castor ^ss. 

aloes compos, 31L 

opii 3i.— M. S. Take from 30 to 40 drops every hour until 

relieved. 

R. — Tinct. castor ^ss. 

valerian ether §i 

Liq. ammon. succinat. ^ii.— M. S. Twenty drops every hour or two. 
t R. — Rad. valerian §i. 

^ther sulphur. |viii.— M. Digest for three days. Dose from 30 to 40 
drops. 



HYSTERIA. 113 

afford much relief in chronic hysteric affections. I have very often 
prescribed this article with more than mere temporary advantage. 
A wineglassful of the infusion (one ounce of the root to a pint of water) 
may be taken every four or five hours. 

In some instances of chronic hysteria, emetics have been known 
to act very beneficially. Dr. Dean, of Harrisburg, observes, " in 
some cases where the patients had laboured under this disease for ten 
years, and during that time had, by the advice and direction of re- 
spectable physicians, exhausted, with at most but temporary benefit, 
the whole class of remedies which are usually prescribed, I have, by 
the continued exhibition of vomits, either entirely removed the com- 
plaint, or so far interrupted the habits of the diseased action in the 
stomach, that antispasmodics and tonic medicines would, in general, 
complete the cure."* I have, in a few instances, resorted to this 
practice with considerable advantage. Ipecacuanha is the proper 
article for vomiting in this affection. 

In the management of chronic hysteria, it is particularly important 
to confine the patient to a light, unirritating, and digestible diet. No 
permanent relief can be procured where this rule is not rigidly ad- 
hered to. It is equally important to enjoin regular, but not fatiguing 
exercise, by walking or gestation in the open air ; and all unpleasant 
mental excitement, or disagreeable sensorial impressions, should be as 
much avoided as possible. 

Particular and continued attention must, moreover, be paid to the 
state of the bowels. If they are torpid, it will be necessary to order 
some mild aperient, so as to procure regular alvine evacuations. For 
this purpose, I know of no medicine so beneficial, in cases of this kind, 
as the following pills.t 

In the remedial management of this form of hysteria, it is especially 
necessary to attend to the exciting causes of the disease. Neither 
proper regimen, nor the use of anodynes, antispasmodics, or tonics, 
will procure more than very incomplete and temporary advantage, so 
long as a fixed local irritation exists somewhere in the system. The 
primary object, therefore, should be, to ascertain, if possible, whether 
there is any source of irritation present. If no obvious exciting cause 
of this kind can be detected, which is indeed but very rarely the case, 
and the disease appears to depend mainly on a morbid irritable con- 
dition of the nervous system in connection with general debility, 
advantage may be expected from the use of tonics, in conjunction 
with a mild, digestible, and nourishing diet; regular exercise in the 
open air, and agreeable society. The ferruginous preparations will, 
in general, answer better in cases of this kind than the usual vegeta- 

* Medical Recorder, vol. iv, p. 259. 
t R. — Massse pill, hydrarg. Qii. 
G. aloes gr. xx. 
Tart, antimon. gr. ii. 
Pulv. capsici ^ii. 

Mucilag. g. Arab. q. s. — M. Divide into 40 pills. Take two every other 
night. 

VOL. II. 9 



114 HYSTERIA. 

ble tonics. Iron is a peculiarly valuable tonic, in instances where, 
along with an irritable and vascular system, the general habit is 
relaxed, enfeebled, and sluggish, and the digestive powers habitually 
feeble. The preparation I have found most beneficial in such cases 
is the prussiate of iron.* When given in full and regular doses, it 
scarcely ever fails to moderate the frequency of the pulse, whilst its 
fullness is increased. This article, in fact, possesses the power of at 
once diminishing the morbid irritability of the system, and of invigo- 
rating its powers. I have been much in the habit of employing it in 
diseases attended with great irritability and weakness, and frequently 
with the most decided advantage. It would seem that the prussic 
acid which it contains is sufficiently separated from its base by the 
vital actions, to exert its peculiar influence on the system. The cold 
infusion of wild cherry bark also is an excellent tonic in chronic 
hysteric complaints. In cases of this kind, much benefit may be ob- 
tained from the use of the shower-bath, in conjunction with the mea- 
sures just indicated. The water should at first be tepid and impreg- 
nated with salt, and the temperature afterwards gradually reduced, 
in proportion as the energies of the system are invigorated. 

Where, however, there is a fixed local irritation present, tonics 
are in general not only useless, but frequently injurious. Should the 
irritation exist in the alimentary canal, from a torpid and loaded 
state of the bowels, a course of mild purgatives must be instituted 
before recourse can, with propriety, be had to tonics. In instances 
connected with menstrual irregularities, efforts should be made to 
obviate this source of general irritation. The most common uterine 
disorder accompanying and supporting chronic hysteria, is profuse 
leucorrhcea and prolapsus uteri. I have within the present year 
succeeded in relieving two patients, who had for many years been 
almost continually afflicted with distressing nervous symptoms and 
debility, by the use of astringent injections into the vagina, the intro- 
duction of pessaries, and the internal use of tonics. Both these 
patients laboured under profuse leucorrhcea, apparently entirely in 
consequence of very great prolapsus uteri. 

Chronic hysteria is also frequently connected with habitual menor- 
rhagic discharges. This is particularly apt to be the case about the 
period of the final cessation of the menses. In instances of this kind 
much advantage may sometimes be derived from minute doses of 
aloes, in conjunction with the use of from thirty to forty drops of the 
tincture of cinnamon three or four times daily. 

In some instances chronic hysteria depends on phlogosis of the 
mucous membrane of the alimentary canal 1 . I attended a lady last 
summer who had been almost continually affected with various hys- 
teric symptoms for several years. She had used much medicine, but 
with little or no advantage. I found her epigastrium somewhat tense, 

* R. — Prussiat. ferri 3i. 

G. Aloes socc. gr. xv. 

Conserv. rosar. q. a.— M. Divide into 30 pills. Take one every four 
hours. 



PUERPERAL CONVULSIONS. 115 

and very tender to the touch. Leeches were directed over this region, 
and afterwards frictions with tartar emetic ointment — and the lightest 
farinaceous diet enjoined. By the use of these applications, without 
any other remedial means, her health was completely restored. 

Occasionally habitual nervous symptoms are excited and main- 
tained by intestinal irritation from an accumulation of feculent and 
other irritating substances. When the bowels are torpid, the abdo- 
men tumid and hard, the alvine discharges small and unnatural, the 
breath fetid, the appetite variable, and the patient complains of an 
itching in the nose, a course of laxatives— or what is perhaps better, 
the daily use of purgative enemata, with a mild diet, an occasional 
small dose of blue pill, and small portions of infusion of any of the 
tonic vegetable bitters, constitutes an appropriate course of treatment. 

When the disease is attended with a morbid exaltation of the 
sexual propensities — a circumstance which we sometimes detect by 
the actions and conversation of the patient — or of which we are 
informed by the candid and very proper avowal of the sufferer — 
camphor, in union with hyoscyamus — regular exercise, sleeping 
on a hard matress, early rising, the cold or tepid shower-bath, and 
traveling, will rarely fail to afford particular benefit. 

The cold bath is always a powerful auxiliary in the treatment of 
hysteric affections. Where the debility is great, tepid water ought 
at first to be used for bathing, and the temperature gradually dimi- 
nished, if we find the system sufficiently energetic to react after 
coming from the bath. In general, much more advantage will be 
derived from the shower-bath than from other modes of applying 
the water ; and we may enhance the beneficial effects of the bath 
by adding a considerable portion of salt to it. Sea-bathing, with 
exercise by walking, or gestation, rarely fails to improve the health 
of nervous patients. Chalybeate mineral waters, in conjunction with 
agreeable society, and free motion in the open air, is also a most 
excellent remedial means in cases of this kind. 



Sect. VIII. — Puerperal Convulsions. 

Eclampsia Gravidarum el Parturientium. 

The term puerperal, given to this form of convulsive disease, is 
not a very appropriate one ; for the puerperal state is by no means 
necessarily connected either as a concomitant occurrence, or as the 
cause of this frightful affection. The condition of pregnancy seems, 
however, in some way or other, very essentially concerned in its 
causation. Dr. Dewees thinks that this disease may occur in preg- 
nant women from causes unconnected with gestation. This may be 
true; but the state of pregnancy would, nevertheless, seem to have 
an especial agency in modifying or aggravating convulsions, from 
whatever immediate exciting cause they may arise. W T hat ; we may 
ask, gives to this variety of convulsive disease its peculiarly dan- 
gerous and fatal character ? It can only be attributed to certain cir- 



116 PUERPERAL CONVULSIONS. 

cumstances connected with advanced pregnancy, or with the process 
of parturition. It is, indeed, highly probable, that the disease under 
consideration is essentially an epileptic affection, aggravated and 
supported by the influence of the gravid uterus. Epilepsy is, mani- 
festly, always attended with strong vascular turgescence in the brain, 
and the same condition is as obviously present in puerperal convul- 
sions. Epilepsy is not, however, a very dangerous affection ; whereas 
eclampsia gravidarum is always peculiarly hazardous. Whence 
then this striking difference of severity between these two affections? 
May it not depend chiefly on the tendency of the distended uterus, 
in the latter period of gestation, to favour the determination of blood 
to the head, and to keep up the vascular turgescence in the brain ? 
If by the peculiar position, or great distension of the uterus, the large 
arteries in the lower part of the abdomen are in some degree com- 
pressed, the blood will, one may presume, be more abundantly deter- 
mined to the vessels of the head ; and if the vascular turgescence in 
the brain be very strong, a paroxysm of convulsions may be the 
result. If, then, a fit of convulsions is thus excited or brought on 
by causes not immediately connected with pregnancy, the paroxysm 
will be aggravated and supported by the continued effects of the 
enlarged uterus in determining the blood to the head. 

In epilepsy attacking females in the early months of pregnancy, 
or in the unimpregnated state, there is but little immediate danger to 
be apprehended ; for the vascular turgescence in the brain is not 
supported by a permanent cause of sanguineous determination to the 
head. When the disease, however, is excited by pressure of the 
uterus upon the large arteries in the lower portion of the abdomen, 
or at the entrance of the pelvis, the cause which in the first place 
produces the cerebral congestion, and consequently the convulsions, 
continues and maintains, or still further increases the vascular tur- 
gescence within the head, and can hardly fail to give rise to fatal 
effusion, if the general mass of the blood be not promptly and greatly 
diminished by venesection, or the foetus be not speedily expelled 
from the uterus to enable this organ to contract. The premonitory 
symptoms, the character of the remedies calculated to do good, and 
the phenomena of the disease itself, all indicate in the most unequi- 
vocal manner, that it is preceded and accompanied by strong san- 
guineous congestion in the head ; and the exclusive confinement of 
the disease in its characteristic form to the latter period of gestation, 
when the uterus has attained its greatest volume, as well as the 
occasional complete subsidence of the convulsions when delivery is 
speedily effected, afford very plausible evidence that the cerebral 
congestion upon which the paroxysm probably immediately depends, 
is either the direct consequence of, or strongly promoted by an impe- 
diment offered to the arterial circulation in the abdomen from pres- 
sure by the distended uterus. 

The attack of puerperal convulsions is invariably preceded by 
premonitory symptoms indicative of strong determination to the 
brain. In some instances, they are experienced for many days pre- 
vious to the occurrence of the paroxysm ; in others, they occur only 



PUERPERAL CONVULSIONS. 117 

a few hours before the supervention of the attack. They consist in 
a sense of fullness, weight, tension, severe and deep-seated pain in 
the head, vertigo, ringing in the ears, temporary blindness, weakness 
of the inferior extremities, a fullness of the vessels of the head, and 
occasionally a severe dull pain in the stomach. 

After these symptoms have continued for a longer or shorter 
period, the patient is suddenly seized with convulsions. The mus- 
cles of the face are in a state of rapid convulsive action, and the 
whole body is frightfully agitated, as in severe cases of epilepsy. In 
some instances, the convulsive actions are stronger on one side than 
the other. During the paroxysm, the face is flushed, livid, and turgid 
with blood ; the tongue is thrust out between the teeth ; the carotids 
beat violently, and the jugulars and veins of the head are greatly 
distended ; the respiration is at first hurried, with a sputtering noise 
of the lips, and towards the conclusion of the fit, a copious dis- 
charge of frothy saliva issues from the mouth. The pulse is at first 
full, strong, and tense, becoming afterwards smaller, rapid and eventu- 
ally almost imperceptible. (Dewees.) 

The subsidence of the paroxysm is always gradual; "the force 
and frequency of the convulsions abate, the pulse becomes more dis- 
tinct and less frequent ; the breathing is less hurried and less oppress- 
ive ; the face loses part of its lividity ; the muscles are agitated only 
at intervals, and their action resembles the commotion excited by 
passing a brisk electric shock through them, and eventually sink into 
repose. The patient, however, remains for the most part insensible 
or comatose, with stertorous breathing or loud snoring ; she cannot 
be roused by any exertion for some time, and if she recover, for a 
moment, her scattered senses, she is without the slightest recollec- 
tion of what passed. This truce is almost always of short duration; 
convulsion follows convulsion, without our being able to determine 
the period or the cause of their return." 

Dr. Dewees has divided this affection into three varieties — namely, 
the epileptic, the apoplectic and the hysteric. It does not appear 
clear, however, upon what grounds he has founded the second vari- 
ety ; for he points out no material circumstances by which it is dis- 
tinguished from the epileptic variety. What he calls the apoplectic 
variety of the disease, is evidently only a higher grade of the epilep- 
tic variety, and differs from it merely in the greater degree of vascular 
turgescence in the brain, and the increased liability to fatal extrava- 
sation or effusion. Puerperal convulsions, as I have already observed, 
appear to be essentially epileptic — that is, immediately dependent on 
strong sanguineous congest ion in the encephalon, from whatever 
cause this may arise. When the determination to the head is very 
great, the symptoms will assume more or less of an apoplectic cha- 
racter, or fatal extravasation may be the consequence. 

The division of the disease into the epileptic and hysteric varie- 
ties, however, is founded on correct pathological principles, and is 
especially important in a practical point of view. It would, indeed, 
be more proper, perhaps, to consider them as distinct forms of con- 
vulsions — the one essentially hysteric, the other epileptic. Although 
hysteria is by no means a common affection after the term of quick- 



118 PUERPERAL CONVULSIONS. 

erring in pregnancy, hysteric convulsions may, nevertheless, occur 
from the ordinary exciting causes of this affection during utero-ges- 
tation, in individuals of a nervous temperament or an hysterical 
habit. The hysteric variety of this disease is often excited by mental 
emotions, and 'may be distinguished from the epileptic form by the 
premonitory symptoms, which are generally distinctly hysterical- 
such as violent palpitation of the heart, a feeling of faintness, globus, 
hystericus, a pale instead of a suffused countenance, &c; and by the 
phenomena of the paroxysm, which, though indicative of violent 
nervous irritation, do not manifest any very violent degree of vas- 
cular turgescence in the head. The face is not much flushed, and 
in some instances remains even of a pallid hue. The larger muscles 
are agitated with extreme violence ; and those on the posterior part 
of the body are generally thrown into a state of violent tonic con- 
traction, causing a rigid recurvation of the body — the head and 
lower extremities being drawn backwards, whilst the breast, abdo- 
men, and hips, are thrown forwards into an arch, as in tetanus. 
" There is no frothing at the mouth ; and the patient, after the fit, 
can, for the most part, be roused by attention, or will frecmently be- 
come coherent as soon as she recovers from the fatigue or exhaus- 
tion occasioned by the violence of her struggles, and though she may 
lie apparently stupid, she will, nevertheless, sometimes talk or indis- 
tinctly mutter. After the convulsion has passed over, she will often 
open her eyes and vacantly look about ; and then, as if suddenly 
seized by a sense of shame, will sink lower in the bed, and attempt 
to hide her head under the clothes."* 

Treatment. — From what has already been said concerning the 
pathology of this affection, it is manifest that in the epileptic form 
of the disease, the principal indication is to lessen as speedily as 
possible the sanguineous engorgement of the vessels of the brain. 
The treatment, in short, differs in no essential point from that which 
is proper in apoplexy. Blood should be promptly and copiously ab- 
stracted. This measure may be regarded as absolutely indispensable 
to success in the management of this affection. In a case which I 
lately saw in consultation with Dr. Dunn, nearly forty ounces of 
blood were at. once abstracted. This evacuation, together with sina- 
pisms to the feet and purgative enemata, succeeded in removing the 
disease, and the patient was, in about a week afterwards, delivered 
of a healthy child without any further unfavourable occurrences. 
In conjunction with copious abstractions of blood with a lancet, local 
bleeding by cupping from the temples or shaven scalp, may be of 
material service. Much benefit may also be derived from cold ap- 
plications to the head, while sinapisms are applied to the inferior 
extremities. The rectum should be evacuated by laxative enemata; 
and as soon as the patient is able to swallow, an active cathartic 
ought to be administered.! These constitute almost the only useful 

* Dewees. 

t R. — Calomel gr. x. 

P. jalap gr. x. 

— aloes gr. v.— M. To be taken all at once. 



PUERPERAL FEVER. 119 

or proper remedial means in the treatment of this form of convulsive 
disease. When the disease occurs near the termination of the period 
of gestation, labour is almost always brought on ; and it should be 
a rule to deliver as speedily as can be done with propriety ; for the 
expulsion of the foetus often puts a termination to the recurrence of 
the paroxysms. Such a favourable result is, however, not always 
obtained from the evacuation of the uterus. When the onset of the 
disease has been violent, and the cerebral congestion is strong and 
continuous, the paroxysms will recur again and again after the de- 
livery of the child is effected ; and such instances rarely terminate 
otherwise than in death. If the os uteri is somewhat dilated and 
dilatable without much effort, it is best, nevertheless, to deliver at 
once by turning and bringing down the feet. I have in two instances, 
delivered in this way with the happiest effect on the disease. In 
another case, however, a patient of Dr. M'Clellan, the result was 
not favourable. The delivery was easily accomplished, and the pa- 
tient appeared to do well when I left her. She was induced, how- 
ever, by her friends, to take a little whisky, " to strengthen her 
heart," (she was an Irish woman ;) and the consequence was a re- 
turn of the paroxysms, which soon terminated her life. When the 
os uteri is rigid, no advantage can be obtained by forcibly dilating 
it and delivering by the feet. In such cases, it is better to wait until 
the head is forced down in the cavity of the pelvis, and to deliver 
with the forceps as soon as it can be accomplished. 

In the hysteric variety of the disease, bleeding, though not so ab- 
solutely indispensable as in the former variety, can, nevertheless, not 
be prudently dispensed with. In general, from sixteen to twenty 
ounces of blood taken from the arm will suffice in cases of this kind. 
Where, however, the momentum of the circulation is strong, and 
the symptoms indicate much engorgement of the vessels of the 
head, the bleeding must be continued without any regard to quantity 
until the action of the pulse is decidedly moderated. The rectum 
should also be immediately emptied by purgative enemata, and sina- 
pisms may be applied to the wrists and feet. If, from the constitu- 
tional habit of the patient, the nature of the exciting cause, and the 
premonitory and actual symptoms of the case, there is no reason to 
doubt of its hysterical character, recourse should be had, after the 
foregoing means have been used, to opiates and antispasmodics. A 
full dose of laudanum with an assafetida enema, will, in general, 
answer better for this purpose than any other remedies of this kind. 
The case, in short, should be treated as a paroxysm of hysteric con- 
vulsions.* Instances of this kind very rarely terminate fatally. Dr. 
Dewees has never known an instance of death from this variety of 
the disease. It is equally rare that, parturient pains are excited by 

* [It is in such cases as these that the Indian hemp, lately introduced to the 
notice of the profession by Dr. Shaughnessy, is most serviceable. The late Dr. 
Klapp afforded immediate and permanent relief in one instance by the adminis- 
tration of a grain dose, after the unsuccessful use of other antispasmodics and 
stimuli. — Mc] 



120 TETANUS. 

this affection. When it occurs in the early periods of pregnancy, 
however, it may give rise to abortion— an instance of which occurred 
to me a few years ago. 

Sect. IX.— Tetanus. 

Tetanus consists in violent tonic spasms of the voluntary muscles, 
with the powers of sensation and thought unimpaired. There exists, 
therefore, a radical difference between this disease and the affections 
which are properly called convulsive; for in the latter forms of spas- 
modic disease, more or less disorder of the sensorial and intellectual 
powers almost always exists, and the spasmodic affection is character- 
ized by sudden contractions and relaxations of the voluntary muscles, 
alternating in quick succession, giving rise to violent concussive mo- 
tions of the body and extremities. 

Tetanus is divided by nosologists into different varieties, according 
to the particular set of muscles chiefly affected. When the affection 
is confined to the muscles of the jaws and throat it is called trismus, 
or locked-jaw. Sometimes the extensor muscles of the trunk and 
inferior extremities are principally implicated, causing a rigid recur- 
vation of the body, so as to bend it violently backward into the form 
of an arch — and this variety is denominated opisthotonos. The term 
emprolhotonos is applied to the disease when the body is curved for- 
wards; and pleurothotonos designates its lateral incurvation. These 
distinctions possess no practical importance — the disease being essen- 
tially the same in all of them. There is another distinction, however, 
founded upon etiological circumstances, which it is of more conse- 
quence, both in a prognostic and therapeutic point of view, to bear 
in mind: — namely, the division of the disease into idiopathic and 
traumatic tetanus. The former term is applied to those cases which 
arise from the operation of general causes ; such as cold, or narcotic 
poisons ; the latter designates those instances which occur in conse- 
quence of some mechanical injury; such as wounds, bruises, burns, 
and other organic lesions. 

Tetanus almost always approaches gradually — so that several days 
often elapse between the first manifestations of its invasion, and its 
state of complete development. At first, slight spasmodic sensations 
are usually felt in the muscles of the larynx ; in consequence of which 
the voice undergoes some change, and deglutition sometimes becomes 
slightly affected. About the same time an uneasy sensation is occa- 
sionally felt in the prsecordial region, and soon afterwards a feeling 
of stiffness occurs in the muscles of the neck, and about the shoulders. 
The muscles of the jaws now begin to stiffen. At first this rigidity 
is not so great as to prevent the patient from opening his mouth to a 
considerable extent. The contraction, however, increases with more 
or less rapidity, until the teeth of the upper and lower jaws are im- 
movably pressed against each other. When the disease has advanced 
to tins stage, sudden and painful retractions about the scorbiculus 
cordis occur at intervals, accompanied by a simultaneous retraction 



TETANUS. 121 

of the head and an aggravation of the symptoms already mentioned. 
Deglutition, even during the intermissions of these paroxysms, is now 
performed with pain and difficulty, and is apt to excite a return of 
the spasms. As the disease advances, the pain and retraction at the 
epigastrium return every ten or fifteen minutes, in exceedingly vio- 
lent paroxysms, and are always immediately followed by a powerful 
spasmodic retraction of the head, and a rigid contraction of almost 
every muscle of the body. The muscles of the chest and throat 
are violently and painfully contracted; the arms and legs forcibly ex- 
tended; the shoulders thrust forwards; the abdominal muscles firmly 
retracted against the viscera; and the whole frame thrown into a most 
painful and unyielding state of tonic spasm. These paroxysms last 
usually but a few minutes — the muscles of the trunk and extremities 
resuming for a while a comparatively relaxed state ; but those of the 
jaws remain firmly contracted during the remissions. In the latter 
period of the disease, the spasms remit but slightly and transiently : 
the patient is in almost a continued rack of torture ; the muscular 
contractions are general and extremely violent ; the countenance be- 
comes frightfully distorted ; copious sweats break out ; the pulse is 
quick and irregular ; the respiration hurried and laborious ; the voice 
grating and unnatural ; the eyes dim and watery, and the jaws im- 
movably locked. Towards the fatal termination of the disease slight 
delirium generally occurs. ' At this period a severe spasm often ter- 
minates the scene. 

The usual mode of termination in fatal cases is by apoplexy. In 
some instances, all the muscles become completely relaxed a short 
time before death takes place. The patient seems to have emerged 
from this terrible malady. Every part of the body is in the ordi- 
nary state of relaxation. Suddenly, however, extreme prostration of 
strength ensues. He becomes insensible and comatose ; the counte- 
nance assumes a cadaverous expression, and death speedily follows.* 

It is worthy of notice, that the muscles which are supplied with 
ganglionic nerves, as well as those which derive their nerves imme- 
diately from the brain, do not become affected until towards the fatal 
termination of the disease. The muscles of the fingers and the tongue 
are seldom affected until the disease has accquired its utmost degree 
of violence. 

The mind is very rarely disordered in tetanus. I have seen in- 
stances in which the intellectual powers remained entire up to the 
last moment of the disease. The appetite and the digestive functions, 
also, are generally but little affected. During the paroxysms the pulse 
is contracted, hurried, and irregular, and respiration is affected in like 
manner. In the remissions, both the pulse and respiration usually do 
not differ much from their natural conditions. 

The duration of tetanus is various, although it. commonly termi- 
nates before the fifth or sixth day, and not unfrequently as early as 
the third day. In some instances, however, it continues much longer, 
and occasionally it assumes a chronic character. (Richter.) When 

* Richter, Specielle Therapie, bd. viii, p. 368. 



122 TETANUS. 

the disease is about terminating favourably, the remissions become 
more complete and protracted, during which, patients frequently 
experience a sense of formication in the extremities. It always 
passes off very gradually, and in general the pectoral and abdominal 
muscles are the last to regain their healthy condition. An increased 
irritability of the nervous system and generally weakness continue 
several months after recovering from an attack of tetanus. Accord- 
ing to the statements of some writers, tetanus sometimes passes into 
other forms of disease. Stark states that it has been known to 
terminate in remitting and intermitting fevers.* Instances have also 
been recorded, in which paralytic affections remained after the sub- 
sidence of the disease. (Richter.) 

Causes. — Tetanus is most apt to occur in young, and robust in- 
dividuals of irritable habits of body. It is rarely met with in persons 
of very advanced age ; new-born infants, however, are peculiarly 
liable to its attacks. High atmospheric temperature appears to exert 
a powerful influence in predisposing the system to tetanus. It in- 
creases the general irritability, and by exciting inordinately the 
perspiratory function, renders the system more susceptible of the 
injurious influence of sudden applications of cold. It is on this 
account, that idiopathic tetanus is so much more common in hot than 
in the temperate and cold latitudes. In intertropical countries, it 
occurs most frequently along the sea-coast and in elevated situations. 
The cool sea-breeze during the night, after the heat of the day, seems 
in such localities to be the ordinary exciting cause of idiopathic teta- 
nus. Schmucker states that tetanus occurred very frequently in the 
Prussian army from slight wounds in the mountainous districts of 
Bohemia, where in summer the days are extremely warm and the 
nights uncomfortably cool. 

The exciting causes, as has been already intimated, are of two 
kinds, namely : — such as produce local or structural lesion ; and such 
as affect the system by a general influence. Of the former kinds are 
wounds or mechanical injuries; and of these, contused, lacerated, 
and punctured wounds, are most apt to give rise to this affection. 
Tetanus is particularly apt to follow wounds in which a nerve is 
partly divided, or lacerated without being completely divided. The 
insertion of an artificial tooth, (Plenk,) including a nerve in a ligature 
passed round an artery; amputation; the extirpation of tumours; 
compound and comminuted fractures ; gun-shot wounds ; cutting corns 
on the feet too closely ;t the sudden access or introduction of cold air 
into wounds, particularly of gun-shot wounds, when the sloughs are 
about being thrown off, (Larrey ;) in short, every kind of incised, 
punctured, lacerated, or contused wounds, however trivial, may, 
under favourable circumstances, give rise to this affection. I once 
met with a very remarkable instance which appeared to have been 
excited by the irritation of a dead foetus in utero.t Tulpius mentions 

* De tetano ejusque specibus prsecipuis, causis et ratio curandi, p. 169. 

t I have seen a fatal case produced in this way. 

% This case occurred about eight years ago. A poor woman, in the ninth month 



TETANUS. 123 

a case of tetanus from suppurative ulceration of the bladder in con- 
sequence of calculous irritation.* Richter has known it occasioned 
by the removal of an encysted tumour from the cheek ; and De Haen 
mentions an instance which was excited by the application of lunar 
caustic to a similar tumour.t A case is mentioned by Bajon.J which 
was caused by the application of an escharotic to an ulcer on the leg. 
Instances of tetanus produced by gangrenous wounds are mentioned 
by Mursinna,§ Hopfengaertner, and White. The most dangerous 
wounds, however, in this respect, are punctures of tendinous, aponeu- 
rotic, and very nervous parts— as the palms of the bands, soles of the 
feet, and under the nails of the fingers and toes. Traumatic tetanus 
frequently does not come on until the wound which gives rise to it 
has cicatrized. Most commonly the disease supervenes about the 
eighth or ninth day, and this is especially the case when it arises from 
gun-shot wounds. Sir J. M'Grigor asserts that if tetanus does not 
occur within twenty-two days after the injury has been received, the 
patient may be regarded as free from danger on this account. || 

Among the general causes of this affection, cold, suddenly suc- 
ceeding high atmospheric temperature, is decidedly the most power- 
ful. Sleeping in the open and cool night air is a very common 
exciting cause of tetanus in hot climates. The influence of cold 
appears to be particularly favourable to the occurrence of this disease 
from wounds or mechanical injuries. I have already referred to the 
observations of Schmucker and Larrey on this point, and Mursinna 
has noticed this circumstance particularly. When the disease occurs 

of pregnancy, who resided at Bush-Hill, came to my office for medical advice. 
She walked into town, and appeared to be healthy. She complained, however, 
of an inability to open her jaws, and 1 found that she could not separate the teeth 
more than about an eighth of an inch. She conld assign no cause for this affection. 
I ordered her to be bled, and to apply a blister on the back of the neck. Next 
day I was requested to visit her. I found her much more indisposed than on the 
previous day, and the jaws were now firmly locked, with slight spasmodic con- 
tractions of the muscles of the throat. I bled her profusely, gave her another 
cathartic, and applied caustic potash over the track of the temporal muscles, and 
along the course of the cervical vertebra. On the following morning, I found her 
affected with distinct and general tetanic paroxysms, which gradually became 
more and more violent and frequent. In the afternoon, I discovered, during the 
intermissions of the spasms, that labour had commenced. On examination, I 
found the os uteri considerably dilated, and the head of the fcetus in the cavity of 
the pelvis. I immediately sent off for a forceps, and in the course of about half an 
hour after, delivered her of a dead and partially putrid foetus. The tetanus, never- 
theless, continued, and terminated in death on the following morning. I observed 
that the parturient contractions of the womb, and the tetanic spasms, recurred in 
regular alternation. 

* Observ. Med., Amst., 1672, lib. iii, cap. ii. 

t Ratio Medend., Pars, vi, cap. iv. § ix. 

X Journ. de. Med., t. xxx, p. 419. 

$ Journ. f. Chirurgie, 1820, b. i, st. iii. 

II Medico-Chirurg. Transact., vol. iv, p. 449. 



124 TETANUS. 

from this cause, it generally comes on about the third or fourth 
day of the exposure. The very frequent or endemic occurrence of 
tetanus in southern climates— at Barbadoes, Java, St. Domingo, Cay- 
enne, and generally in the Antilles, as described by Hillary, Pouppee, 
Desportes, Bajon, Moseley, Blane, Clark, and others, must be ascribed 
to the combined, or rather alternate influence of high atmospheric 
temperature, and of cold and damp night air. Tetanus may also be 
produced by drinking cold water while the body is in a state of free 
perspiration from fatiguing exercise in warm weather. Rush, Mur- 
sinna* and Stuitzt mention instances occasioned in this way. Te- 
tanic spasms sometimes occur in the latter stage of severe forms of 
fever. 

Pathology.— From seeing those muscles particularly affected which 
derive their nerves from the spinal marrow — whilst those which are 
supplied with ganglionic nerves are, in a great measure, exempt from 
spasm; as well as from the undisturbed state of the sensorial and 
intellectual functions — tetanus was, at an early period of our science, 
referred to the spinal marrow as its primary and essential location.} 

This view of the pathology of tetanus is founded chiefly on the 
phenomena usually detected in the spine on post-mortem examina- 
tion ; and on the artificial production of tetanic symptoms by certain 
mechanical injuries of the spinal marrow. Dr. John Frank was the 
first who directed the attention of physicians particularly to the mor- 
bid appearances of the spinal marrow in those who die of tetanus. 
In one instance he found the spinal matter soft and considerably 
altered in structure, with effusion of serum between its coats, and 
an engorged state of the blood-vessels. In another case, strong 
traces of previous inflammation were detected throughout the whole 
extent of one side of the spinal prolongation^ Dr. Reid afterwards 
published a paper, [loc. cit.,) from which it would appear that the 
principal seat of the inflammation is in the membranes of the spinal 
cord. In an extremely violent case, he found a whitish soft sub- 

* Journ. f. Chirurgie, b. i, st. iii, p. 406. 

t Medic. Annalen., 1802, p. 756. 

% Galen was of this opinion; and Willis, Fernelius,(o) Burserius ; (6) Hoff- 
man, and more recently Frank, Marcus, d'Oulrepont, (c) Walther, Schaal,(r/) 
Le Galois, Brera, Thompson, Abercrombie, Harles, Rachetti, Esquirol, Copeland, 
Carter, Philip, Brodie, 0'Bierne,(e) Reid,(/) Saunders, and others, have ex- 
pressed similar views. 

$ The side of the spinal matter, which was thus affected, corresponded with the 
hand injured that gave rise to the disease. 

(a) De Medicina Universa. — Pathol, vi, ch. iii, p. 417. 

(b) Institutiones Med. Pract, vol. iii, p. 201. 

(c) Salzburg. Medicinische Chirurgische Zeitung., No. xxxiv. 1818. 
{<!) Dissertat. de Tetano, Berol, 1820. 

(e) Dublin Hospital Reports, vol. iii. 

(/) Transact, of an Associat. &c. of the King and Queen's College of Physicians 
in Ireland; vol. viii, 



TETANUS. 125 

stance deposited between the arachnoid membrane and the pia mater. 
In less violent cases, serous effusions were found between the mem- 
branes. Similar observations have been published by d'Outrepont, 
Walther, Saunders, Abercrombie, Broussais, Monot, Jobert,* and 
other pathologists. This pathology of tetanus is, moreover, supported 
by the fact, that tetanic spasms may be artificially produced in ani- 
mals by thrusting a slender wire along the spinal canal, so as to irri- 
tate the marrow without materially compressing it. This experiment 
has been frequently performed by Dr. Walther, of Berlin, with the 
most striking results ; and similar consequences were witnessed from 
this operation by Le Galois, Philip, Brodie, and other physiologists. 
The fact, therefore, that strong marks of inflammation in the spinal 
prolongation of the encephalon are very common post-mortem phe- 
nomena in tetanus, appears to be sufficiently established. It may, 
nevertheless, be doubted whether these morbid conditions of the 
spinal cord be the proximate and essential cause of the tetanic spasms, 
or only secondary, and one of the ultimate consequences of the dis- 
ease. If, on the one hand, this view of the nature of the disease be 
favoured by the occasional successful employment of topical bleeding, 
blistering, irritating and cauterizing applications along the course of 
the spine, it is, on the other hand, as strongly discountenanced by 
the equally frequent beneficial effects of alcoholic liquors, and other 
powerful internal stimulants. It is highly probable, notwithstanding, 
that there exists, as an essential link in the chain of causation, strong 
irritation in the spinal marrow and its membranes, which, in most 
instances, give rise to vascular turgescence, and in the progress of 
the malady, to inflammation and consequent effusion or disorgani- 
zation. Inflammation and its consequences are, I presume, not essen- 
tial to the production of the disease, but a consequence only of the 
spinal irritation upon which the spasmodic affection depends.t 

Mr. Swan, a few years ago, published an essay on this disease, 
in which several cases are related, tending to show that tetanus 

* Monot and Jobert's report of some casesthat occurred in the Hospital St. Louis 
and St. Antoine. Medico-Chirurg. Rev. ; January, 1827. 

t Dr. M. Funk, a German physician, has lately published an account of seve- 
ral dissections of persons who had died of tetanus. In the first case, the dura 
mater was reddened in the cervical portion of the spinal cord ; about the first 
dorsal vertebra, and below it, the canal was filled with extravasated blood, which 
had also extended a short distance along the nerves. In the lumbar region the 
extravasation was greatest, and the dura mater was here considerably thickened. 
The surface of the cord itself was rose-red, the origin of the nerves swelled, and 
the cauda equina much reddened. In another case, a large quantity of bloody 
serum was found between the dura mater and arachnoid, and the vessels were 
very much injected, with some extravasation throughout the whole course of the 
spine. In a third, fourth, and fifth case, equally strong marks of spinal inflam 
mationwere detected, (a) 



(a) Glasgow Medical Journal. 



126 TETANUS. 

depends on irritation and inflammation of the ganglia.* In the cases 
which he reports, the ganglia of the great sympathetic manifested 
unequivocal marks of irritation and disease. The semilunar ganglion 
was, in most instances, strongly injected, and all the other ganglia of 
this nerve were more or less inflamed. 

Prognosis.— The prognosis in this disease is always highly unfa- 
vourable.t Traumatic tetanus is particularly fatal in its tendency. 
Cases that depend on general causes are usually much more under 
the control of remedial management. That variety of tetanus which 
occurs in new-born infants [trismus nascentium), terminates almost 
universally in death. Parry asserts, that if the pulse becomes very 
frequent on the first day of the disease, if it rises above one hundred 
and twenty beats in a minute, the case may be regarded as inevita- 
bly mortal. When, on the contrary, it does not go beyond one hun- 
dred or one hundred and ten beats by the fourth or fifth day, reason- 
able hopes of recovery may be entertained. " When the disease 
comes on gradually, and the muscles of the jaws are alone affected 
during the first three or four days; when the abdomen is not pre- 
ternaturally hard, and the bowels obstinately costive ; when the skin 
is moist and moderately warm; and above all, when the patient 
enjoys sleep, we may entertain strong hopes of an eventual recovery. 
An increased flow of saliva, where mercury has not been used, is 
always to be regarded as favourable ; and the less the general expres- 
sion of the countenance is changed, the better. On the other hand, 
where the attack is violent and sudden ; where the muscles of the 
neck, back and abdomen are rigidly contracted ; when the patient 
complains of a shooting pain from the sternum towards the spine ; 
when the belly feels hard, and the least pressure thereon produces 
spasmodic twitchings or contractions of the muscles of the neck, jaws, 
&c; or when the same effect is brought about by the presentation of 
any substance, solid or fluid, near the mouth, we may have much 
reason to fear a fatal termination.":]: 

Treatment. — When a wound or injury has been received, from 
which tetanus may be apprehended, efforts should be made to pre- 
vent its occurrence, by a proper management of the local injury. 
Experience has fully established the fact that the best means for 
preventing the disease is the production of free suppuration in the 
injured part. When this process can be fully established in wounds, 
even of the most unfavourable character, the occurrence of the dis- 
ease will almost certainly be prevented. It has been frequently 
observed, that the less inflammation there is in the injured part, the 
greater will be the liability to tetanus. This circumstance has sug- 
gested the propriety of exciting inflammation in the wounded part, 
by means of irritating applications. For this purpose we may apply 
spirits of turpentine, lunar caustic, caustic ley, cantharides, or, ac- 

* An Essay on Tetanus, founded on Cases and Experiments. London, 1825. 
t Aretams very justly designates tetanus as, inhumana calamitas, injucundus 
aspectus, triste intuenti spectaculum, et malum insanibile. 

X Dr. Morrison.— Vide Johnson on Tropical Climates, vol. ii. 



TETANUS. 127 

cording to Larry, the actual cautery, followed by warm stimulating 
poultices; or the part maybe incised or scarified, and afterwards 
further irritated by some application of this kind. When nerves or 
tendons are but partially divided by the injury, the division should 
be completed by free incision. General remedies have also been 
recommended with the view of preventing the disease. Larry insists 
strongly on the importance of pre venting the access of cold and damp air 
to wounds, particularly gun-shot wounds, as a prophylactic measure. 
Dr. Thomas states, that in the British army, opium is mixed with the 
dressings as a preventive of this affection. Dr. Potter, of Baltimore, 
states, that he has found no application so useful, in this respect, as 
warm emollient cataplasms.* Dr. Clarkt advises a slight mercurial 
ptyalism after unfavourable wounds, more especially in hot climates. 
An equable and comfortable temperature, with a simple diet and rest, 
is an important auxiliary in preventing the disease after wounds. 

A very great variety of remedies and modes of treatment have 
been proposed, and occasionally employed with success in this fright- 
ful malady. The practitioner who consults the records of medicine 
for light on the remedial management of tetanus, will probably find 
himself very much perplexed. He will find the doctrine of its de- 
pendence on spinal and ganglionic inflammation strongly counte- 
nanced by examples of post-mortem phenomena; and yet he will 
read, on the one hand, the laconic, but sweeping denunciation against 
the most powerful antiphlogistic — "bleeding is to be condemned ;"J 
whilst, on the other hand, he will find stimulants and tonics repro- 
bated, and prompt and copious depletion pointed out as the sheet- 
anchor of our hopes. He will find Broussais and others, ridiculing 
the idea of treating tetanus with stimulants and antispasmodics ;§ and 
then, turning to Morrison and a great number of other respectable 
authorities, he will learn that these are the very remedies which, in 
their hands, proved most successful. These facts may be irreconcila- 
ble, according to our imperfect views of the pathology of this affec- 
tion, but they are notwithstanding facts, and there is therefore some- 
thing in the nature of the disease, which, in spite of theory, renders 
both exciting and depletory measures, at times, decidedly beneficial. 
To me, indeed, these apparently contradictory statements appear to 
admit of a plausible though hypothetical explanation. Tetanus is 
manifestly an irritative disease. In the traumatic variety, it would 
seem to be the result of a peculiar irritation, passing from the extre- 
mities of wounded nerves to their origin, giving rise to morbid action 
in that part of the nervous centre which more immediately presides 
over the powers of the voluntary muscles. Hence, opium and what- 
ever is capable either of blunting the irritability, or causing a strong 
counter-excitement in the nervous system, may overcome morbid 
excitement and ultimately subdue the disease. As, however, all 

* Note to Gregory's Practice, vol. ii. p. 141. 

t On the Diseases of the West Indies. 

% Elements of the Theory and Practice of Physic, vol. ii. 

S Journal de Med. Phys., Fev., 1827. 



128 TETANUS. 

violent local irritation tends to produce congestion, and finally more 
or less inflammation in the part, this may at times be an early con- 
sequence. Here, general and local depletion will be proper; and, 
if promptly and efficiently practised, in conjunction with other suita- 
ble remedies, before effusion and disorganization have taken place, 
may prove successful. Nay, even direct depletion, and the liberal 
use of opium, are not incompatible, for, while we diminish the 
momentum of the circulation on the one hand, we lessen, on the 
other, the morbid irritation upon which the disease and the inflam- 
mation depend. 

No small number of cases may be cited in which copious blood- 
letting was decidedly beneficial. Mr. Barr bled a young man affected 
with traumatic tetanus, to the extent of fifty ounces at once, plcno- 
rivo. In half an hour the patient's jaws relaxed in some degree, 
and three fluidrachms of laudanum were exhibited. The spasms 
continued, though in less violent and frequent paroxysms. He was 
afterwards bled to the amount of thirty-two ounces on the third day, 
and sixteen on the fourth. Exceedingly large doses of calomel and 
opium were also regularly given. On the fifth day, the disease 
yielded completely.* M. Lisfranc has reported a successful case, in 
which eight bleedings were practiced from the arm, and in the course 
of nineteen days, six hundred and eighty leeches applied along the 
vertebral column.t M. Burmester treated a case of traumatic teta- 
nus successfully by copious blood-letting, opium, mercury, and the 
warm bath.J We may also refer to the case reported by Dr. Alex- 
ander, which yielded to copious and repeated venesection, leeches to 
the abdomen, mercury, and active purging.§ M. Le Pelletier, chief 
surgeon of the hospital at Mans, in an able memoir on this disease, 
observes : " It is neurilematic inflammation that we must attack 
in the treatment of tetanus, and the only means sufficiently powerful 
to subdue it in its bud is venesection, not practised with reserve, but 
with the utmost degree of promptness and freedom. || Local bleed- 
ing by leeches or cups along the track of the spine, is decidedly in- 
dicated in this affection." When we reflect, says Dr. Johnson,'that 
the brain and spinal marrow must be the immediate seat of the irri- 
tation or inflammation which gives rise to the phenomena of tetanus, 
we can hardly look with confidence to any remedy which has not a 
strong tendency to remove this irritation or inflammation. What is 
more likely to effect this indication than powerful and repeated de- 
pletion from the head and spine, but especially from the latter ?T 

Purgatives, also, are important auxiliaries in the treatment of 
this affection. Dr. Hamilton recommends their use as a principal 
curative means ; but he does not adduce any very decisive or direct 

* Edinburgh Med. and Surg. Journ., No. xvii. 
f Rev. Medicale, torn, ii, for 1829, p. 342. 
% Med. Chirurg. Transact., vol. xi, art. xiv. 
$ Edinb. Med. and Surg. Journ., Oct., 1825. 
II Revue Medicale, torn, iv, ann. 1827, p. 346. 
H Medico-Chirurg. Rev., July, 1827, p. 176. 



TETANUS. 129 

evidence from his own experience, in support of the propriety of 
relying chiefly on their employment. He gives, indeed, some state- 
ments from his own practice of the good effects of active purgation 
in what " appeared" to him cases of incipient tetanus, but it may 
be reasonably doubted whether these instances were really tetanic. 
Unquestionably, cathartics deserve to be regarded as highly useful 
remedies in this disease, but we may with propriety, I think, demur, 
when we are advised to rely on them as principal curative means. 
In all instances, perhaps, it will be proper to exhibit active cathartics, 
not only with the view of removing the ordinary sources of intes- 
tinal irritation, but also as revulsive and depletory measures. From 
fifteen to twenty grains of calomel, followed in the course of four or 
five hours with a dose of castor oil and spirits of turpentine, (an 
ounce of the former to two drachms of the latter,) may be given in 
the commencement of the disease, and repeated according to the 
circumstances of the case. In that variety of the disease which oc- 
curs in new-born infants, purgatives have been generally considered 
as indispensable. 

There is no remedy whose good effects in this disease are so fre- 
quently mentioned as opium. One of the latest writers who speaks 
particularly in favour of relying chiefly on this narcotic, is Dr. Mor- 
rison. During eight years of practice at Demerara, where tetanus is 
of frequent occurrence, he employed it in a number of cases, and he 
declares, that in more than a dozen instances, the cure could be fairly 
attributed to this remedy.* Its good effects are, however, not to be 

* [In the only two cases of traumatic tetanus which I have successfully treated, 
I gave from 80 to 90 grs. of solid opium in conjunction with about half the quantity 
of calomel per diem, for several days in succession. In the case of young Mr. 
Bockius, of German town, whom I attended in consultation with Dr. Bunkel, sen., 
we first cut away the comminuted fragments of two metacarpal bones of the left 
hand, which had been shattered by the bursting of a gun, and dressed the wound 
with terebinthinates. We kept up irritation over the whole spine by frictions with 
tartar emetic and croton oil, and gave 82 to 86 grs. of opium a day for about two 
weeks, without producing any coma or oppression. The remedy appeared to 
expend all its powers in allaying the universal tetanic rigidity and spasms. We 
also rubbed mercurial ointment over the limbs and gave calomel in combination 
with the opium until a moderate pytalism was produced. The bowels were kept 
open by occasional doses of croton oil, and the strength was maintained by the 
liberal use of brandy with gruel. In a few days the wound began to suppurate and 
the rigidity and spasms disappeared. The patient has continued well for about 
twelve years. 

The other case of a cure in tetanus to which I have alluded, was that of a house 
carpenter, Mr. M'Glathery, in North Fifth street, who was seized with universal 
rigidity and painful spasms on the ninth day after a deep puncture in the sole of 
one of his feet from a rusty nail. The wound was perfectly dry and more than an 
inch deep, when I laid it open and stimulated it with lunar caustic. It was then 
dressed with spirits of turpentine and basilicon. As he was cold and shivering, I 
continued the hot vapour bath, which a steam doctor had begun to apply, for many 
hours and gave 3 grs. of opium and 5 of calomel every hour till an impression 
VOL. II. 10 



130 TETANUS. 

procured from small doses. It must be given in very large and re- 
peated portions.* Dr. Morrison generally commenced with one hun- 
dred drops of laudanum, and increased each succeeding dose by thirty 
drops every two hours, until either sleep or stertorous breathing came 
on, when it was discontinued. The quantity of opium, which has 
been advantageously given in some instances, is indeed enormous. 
In Dr. Barr's case, referred to above, " a drachm of solid opium was 
given at once," on the third day of the disease, and after eighty-two 
ounces of blood had been abstracted. " In twenty minutes the patient 
began to doze a little, but not to sleep. In about an hour he fell 
asleep, shortly after which the breathing became slow and very labo- 
rious. In two hours he was roused, when he felt nausea, which was 
succeeded by full vomiting, which produced much relief. One slight 
spasm only afterwards occurred." The bowels should always be 
well evacuated by active cathartics and injections, previous to resort- 
ing to the opium. In traumatic tetanus, at least, copious venesection 
and leeching along the spine would appear to be an important pre- 
liminary or concomitant measure with the employment of opium. In 
most of the cases that have been reported in illustration of the good 
effects of copious bleeding, opium was freely administered.t The 
method of Stuitz, which in some parts of Europe has gained much 
celebrity, consists in the alternate use of opium and large doses of 
carbonate of potash, together with warm alkaline baths.J Boucher, 
surgeon of the Hotel Dieu, at Lyons, gave one drachm of opium with 
three of the carbonate of potash in 24 hours with complete success in 
traumatic tetanus. In a recent number of Hufeland's Journal,§ an 
instance of traumatic tetanus is related, in which this mode of treat- 
ment, with a copious blood-letting in the commencement, was used 
with the happiest effect. The method, however, no doubt, derives 
its powers chiefly, if not wholly, from the opium and warm bathing. 
Applied externally, the acetate of morphium has been employed with 
marked success, in this affection. Dr. Jos. Cerioli, of Cremona, has 

was made on the spasms. No narcotic impression was made, although I increased 
the doses to nearly 100 grains a day occasionally. On an average he took full 60 
grains of opium per diem for 12 days, and the calomel was aided by mercurial fric- 
tions until ptyalism was induced. The spine was at the same time irritated by blis- 
ters and tartar emetic ointment. He was supported throughout by the liberal use of 
brandy and gruel, with broths, and finally recovered perfectly. I am sorry to say, 
however, that all the other patients I have seen labouring under tetanus, from 
wounds, have died after every form of treatment. — Ma] 

* A Treatise on Tetanus with Cases. Lond., 1815. 

t Dr. Odier, of Geneva, says, <•' The best means for ascertaining whether the 
disease is tetanus, in doubtful cases, is to exhibit opium in gradually increasing 
doses. If the disease is tetanus, it will require an exceedingly large dose before 
its narcotic effects are manifested. But in cases that simulate tetanus as is some- 
times the case with hysteria, this narcotic evinces its powers much more readily 
and energetically." — Manuel de Medecine Pratique, p. 189. 

% Stuitz, ueber den Wundstarr Krampf, Hufeland's Journal, bd. xviii st iv p 5. 

$ October, 1827. ' ' ' 



TETANUS. 131 

related a case of tramautic tetanus, which, "after copious blood-letting 
and the use of large doses of morphine internally , together with the 
warm, bath, and stimulating frictions along the spine, without any 
advantage, yielded, very soon, to the external application of mor- 
phine. About ten days after the commencement of the disease, the 
cuticle was removed from the back of the neck, by means of an epis- 
pastic. Some acetate of morphium was then applied to the part, and 
repeated in about six hours." The effect produced by this applica- 
tion, was extremely remarkable; in a few hours the clonic spasms 
were weaker, the motion of the jaw more free, the contraction of the 
lineaments of the face became relaxed, the pains of the neck and back 
had diminished sensibly, the sufferer enjoyed a tranquil sleep, with 
slight occasional interruption. By the continued application of this 
narcotic, the patient was finally entirely relieved of the complaint, 
without any other remedy.* 

Mercury, also, has been a good deal employed, and according to 
respectable authorities, with decided advantage in tetanus. Dr. Wal- 
ther, in a memoir on the use of mercury in this affection, declares 
that from successful experience, he is led to regard this remedy as 
among the most valuable means we possess for the cure of tetanus. 
In the Medical Essays and Observations of a Society in Edinburgh, 
published a century ago, Dr. Donald Monro states, that a gentleman 
in Jamaica had cured twelve cases of tetanus in succession " by 
placing his patients in a very warm room, and then rubbing in large 
quantities of mercurial ointment over the limbs and body until ptya- 
lism was raised. This, with large doses of opium, was the only 
means used. Dr. A. Monro, of Edinburgh, tried the same plan in a 
case of traumatic tetanus, and with complete success."! Larrey, 
however, states, that mercurial frictions during the French campaigns 
in Egypt, almost uniformly did harm. Dr. Rush cured a case in the 
Pennsylvania Hospital by copious salivation, assisted by bark and 
wine. It would appear from the observations that have been pub- 
lished on this point, that ptyalism is much more apt to do good in 
idiopathic than in traumatic tetanus. Dr. Morrison states, that he 
met "with many examples of the beneficial effects of mercury in this 
disease, and as it does not interfere with other remedies, the free 
administration of mercury, he says, ought never to be omitted." 

Wine and other alcoholic liquors, though apparently directly 
contra-indicated, have been much used, and successfully too, in teta- 
nus. In conjunction with bark, mercury, and irritating applications 
to the wound, wine was a favourite remedy in this affection with Dr. 
Rush. " Wine," he says, " should be given in quarts and even gal- 
lons daily." Dr. Carrie cured a case in the Liverpool infirmary; the 
patient having drunk, in a short time, " nearly a quarter cask of 
Madeira wine ;" and Dr. Hosack has published observations illustra- 
tive of the beneficial effects of this stimulant in tetanus.f In the 

* London Med. and Phys. Journ., from the Annali Universali di Med. ; May, 
1829. 
t Med. Chir. Rev., vol. x, p. 304. 
X New York Med. Repos., vol. iii, p. 22. 



1 32 TETANUS. 

London Medical and PhysicalJovrnal for March, 1825, Dr. Nicholls 
has reported a case of incipient traumatic tetanus which was suc- 
cessfully treated by the administration of wine, laudanum, bark, and 
steel, with ammonia and nourishing diet. 

Various other stimulants have been employed in tetanus. The 
spirits of turpentine, in particular, has of late years attracted consi- 
derable attention as a remedy in this disease. Dr. Hutchinson gave 
it in a case of idiopathic tenanus, in an epileptic subject, with com- 
plete success.* A similar case is related by Dr. William Tamis, which 
yielded to the internal administration of this article.! Dr. Mott, of 
New York, has given an account of a case of traumatic tetanus, which 
was cured by the spirits of turpentine after the disease had resisted 
the influence of the cold and warm bath, tobacco, opium, bark, wine, 
and blisters to the spine. A teaspoonful of the turpentine was given 
every fifteen minutes for two hours, when the spasms intermitted. It 
was afterwards repeated at longer intervals, until one hundred and 
twenty-three teaspoonfuls were taken.f 

Tobacco was recommended for the cure of this disease by Dr. 
Edmund Gardener as early as the beginning of the eighteenth cen- 
tury. It has lately been a good deal employed, and no inconsidera- 
ble number of instances have been published illustrative of its good 
effects. Dr. O'Beirne's case,related in the third volume of the Dublin 
Hospital Reports, is an interesting example of the occasional bene- 
ficial influence of tobacco in tetanus. Tobacco enemata (a scruple of 
tobacco to a pint of boiling water), were employed at longer or snorter 
intervals, for fifteen days in succession, and the disease was thereby 
completely overcome. Dr. Anderson, who practised at Trinidad, has 
reported three cases of traumatic and idiopathic tetanus which yielded 
under the employment of the tobacco. § He directed the jaws, throat 
and chest to be fomented for half an hour at a time by a strong de- 
coction of fresh tobacco leaves. After the fomentations, cataplasms 
of tobacco were applied to the jaw and throat. The warm bath, into 
which some tobacco was thrown, was also used every three hours, 
and a tobacco enema administered every twelve hours. The trismus 
did not yield until the third day, when the jaws became a little re- 
laxed, and under the same treatment the patients gradually recovered. 
Lefoulon also employed this powerful narcotic with success in teta- 
nus ;|| and Dr. Norcom cured a case by the simultaneous employment 
of opium internally and tobacco clysters.H 

* Lond. Med. and Phys. Journ., No. eclxxxviii. 

t Ibid., for May, 1823. 

% New York Med. and Phys. Journ., vol. ii, p. 388. 

$ Transact, of the Med. Chir. Society of Edinburgh, vol. j ; and vol. ii. 

II Harles' Neue Journ. d. Med. Chir. Leter, b. vi, No. ii. 

H Philadelphia Journal of Med. and Phys. Sciences. [I tried the tobacco in- 
jection in a case of Dr. Goldsmith's in Kensington, and repeated it till we pro- 
duced complete relaxation of the spasms, and prostration of the forces. For a 
season we were gratified with hopes of a cure, but in a few hours the spasms 
recurred and the patient died. — Mc. ] 



TETANUS. 133 

The prtissic acid would appear to possess very considerable re- 
medial powers in this affection. Dr. Trezevant, of Columbia, South 
Carolina, has given the history of a case, which strongly illustrates the 
beneficial tendency of this potent remedy in tetanus.* It appeared, 
also, highly useful in a case treated successfully by Professor Patti- 
son, in which it was freely used, in conjunction with the application of 
caustics along the spine. Various other internal remedies have been 
given with more or less benefit in tetanus. Dr. Brown exhibited the 
tincture of canlharides in large doses with success; and Dr. Elliotson 
has published some observations, which go to show that considerable 
advantage may occasionally be derived from very large doses (§ss) 
of the subcarbonate of iron.t 

The external employment of cold water, either by affusions or the 
plunging bath, is one of the oldest remedies employed in tetanus.^ 
Dr. Wright was the first, in modern times, who directed the attention 
of the profession particularly to the employment of cold affusions 
in this affection. § His observations were soon followed by those of 
Cochran, || and Currie, who fully confirmed the favourable accounts 
he had given of its effects. Dr. Rush also obtained decided advan- 
tages from cold affusions in this disease. The only fortunate case I 
have ever witnessed was treated by mercury, opium, and very fre- 
quent cold affusions. The warm bath, also, has been frequently em- 
ployed in the treatment of tetanus. Richter observes, that the warm 
bath seldom fails to procure at least temporary mitigation of the 
symptoms. Dr. Morrison speaks favourably of the effects of warm 
bathing in tetanus ; but the exertion, he says, which the patient must 
undergo to get in and out of the bath, sometimes does more harm 
than can be counterbalanced by this measure. " Patients (he ob- 
serves), are so alive to all external impressions, that the least exertion 
is often sufficient to excite violent spasms. On this account, the 
patient should be kept as quiet as possible, and very few questions 
asked, and every thing tending to excite mental exertion avoided." 
It must be observed, moreover, that according to the experience of 
some practitioners, much mischief has resulted from the use of the 
warm bath in tetanus, independent of the exertion which it requires. 
Dr. Hillary states, that he has known instantaneous death to follow 
warm bathing in this disease. This, however, may be affirmed of 
perhaps every important remedy that has been administered in 
tetanus. 

From what has been said above concerning the pathology of teta- 
nus, no remedies appear to be more clearly indicated than external 
irritating applications along the track of the spine. This is, indeed, 
an old practice. Celsus lays particular stress on the assiduous em- 

* Medical Recorder, vol. v, October, 1825. 
t Med. Chir. Trans., vol. xv, part i. 

% Hippocrates, lib. iv, sect, v, aph. 2, et lib. v, sect, ii, aph. 21. Avicenna, lib 
iii, cap. 7. 

$ Lond. Med. Observ. and Inquir., vol. vi. 
II Med. and Philosoph. Comment., vol. iii. 



134 TETANUS. 

ployment of frictions and rubefacients over the vertebral column;* 
and if these are insufficient, he advises the application of cups ; or, 
finally, the actual cautery over the vertebrae of the neck. Dr. Wil- 
liam Carter, among modern writers, is, I believe, the first who em- 
ployed blisters along the whole course of the spine in this affection. 
He has published a case which was successfully treated by blistering 
in this manner, with the occasional use of an active cathartic.t Several 
other cases are extant, illustrative of the good effects of this practice. 

A much more powerful and prompt means of this kind is the caustic 
potash. Dr. Hartshorne, of this city, was, I believe, the first who 
applied this caustic over the spine for the cure of this affection. He 
has reported a case which yielded completely under the employment 
of this application, together with the internal use of opium, ether, 
brandy, and extract of stramonium, in large doses. In this case the 
good effects of the caustic were unequivocal. The internal remedies, 
just mentioned, had been employed for several days without any 
advantage. The caustic was at last applied over the cervical verte- 
brae, and in about two hours afterwards a diminution of all the tetanic 
symptoms had already taken place.J A case, equally satisfactory, in 
relation to this practice, is related by Dr. T. Thomas, of Easton, Mary- 
land. After wine, mercurial frictions, and opium, had been ineffec- 
tually employed, the caustic potash was applied over the course of 
the cervical vertebrae. " The effect," says Dr. T., " was really delight- 
ful ; the new action excited by the caustic destroyed completely the 
morbid action of the system ; the spasms ceased, and in one hour the 
patient appeared free from disease. § Many other cases have since 
been published, demonstrating the beneficial effects of this practice.|| 
I have already referred to the recommendation of the actual cautery 
to the region of the cervical vertebrae, in this disease, by Celsus. In 
modern times, Mursinna has resorted to this measure with almost 
instantaneous mitigation of the symptoms. Dr. M'Clellan also em- 
ployed it in one instance with unequivocal benefit. The application 
of moxas, along the spine, might, no doubt, be used with advantage. 

From all that has been said concerning the treatment of tetanus, it 
appears manifest, therefore, that copious bleeding, leeching, and cup- 
ping, along the spinal region, mercury, large doses of opium, tobacco 
enemata, active purgatives, the free use of wine, and caustic applica- 

* Fricatio cum omnibus vertebris, hominum utilis sit, turn iis praecipue, quae 
in collo sunt. Ergo die nocteque ; interpositis tamen quibusdam temporibus, hoc 
remedio utendum est : dum intermittitur imponendum malagama aliquod ex cale- 
facientibus. Si vero etiam vehementius dolor crevit, admovendae, cervicibus 
cucurbituriae sunt, sic ut cutis incidatur. Eadem aut ferramentis aut sinapi adu- 
renda. Celsus, de Medicina, lib. iv, cap. iii. 

t Med. Transact, of the Lond. College of Physicians, &c, vol. ii, p. 34. 
% Eclectic Repertory, vol. ii, p. 245. 

* Ibid. 

II Dr. Worthington, (Medical Recorder, vol. iii, p. 527). Dr. Joel Lewis, (ibid-, 
p. 176.) Professor Potter, of Baltimore. 



HYDROPHOBIA. 135 



tions over the cervical and dorsal vertebrae, constitute the most im- 
portant curative means in ttiis affection. 



Sect. X. — Hydrophobia. 

Hydrophobia is one of the most ancient diseases.* The first dis- 
tinct account, however, which was given of this terrific malady, is to 
be found in the writings of Coelius Aurelianus.t Celsus speaks of it as 
a disease well known before his time. 

In the human species, hydrophobia has never, so far as is known, 
arisen from general causes. In man it is always the result of a spe- 
cific virus or contagion derived from an animal labouring under the 
disease. The hydrophobic virus appears to be exclusively attached 
to the saliva : and hence almost the only mode in which it is propa- 
gated is by wounds inflicted with the teeth of a rabid animal. With- 
out doubt, however, the disease may be communicated by bringing 
the contagious virus in contact with an excoriated or wounded surface 
in any manner. This has indeed been verified by direct experiment. 
Magendie and Brechet inoculated two dogs with the saliva of a rabid 
man. One of these dogs became rabid, and bit two others, which 
also became mad. Instances have, moreover, been recorded of the 
propagation of hydrophobia by the accidental contact of the morbid 
saliva with wounds, or excoriations on the lips, hands, or other ex- 
posed parts of the body.J 

In the dog, fox, and wolf, and in the domestic cat, and perhaps in 
some other animals, hydrophobia is sometimes developed by causes 
of a general character, independent of a contagious principle. By 
what particular influences the disease may be generated without the 
agency of a contagion, is, however, as yet, in a great degree, a matter 
of conjecture. It has been supposed that intense cold and high 
atmospheric temperature have a particular tendency to promote the 
development of this affection. Experience does not sustain this opin- 
ion sufficiently to entitle it to especial credit. It is indeed true, that 
in our own climate, canine rabies is, in general, of much more frequent 
occurrence during the hot months of summer than in any other season 

* Among the ancient Egyptians, rabies canina appears to have been known, 
and ascribed to a disease of the spleen. Horapollo (Hieroglyphica, I. 39) says, 

eirXwa. Jt, 'nriiiri touco to {£)ov /mo'vov •nra^a rk ere^u. eXo^otejov tyii eite (Je) §iva.Tos avrZ, e!te 

/4*v«t TrifiTreToi, k-nl toJ a-wx»voc yivtTai. — Origincs Contagii, Audore Dr. C. F. H. Marx. 
Homer, also, in several places, refers to this disease. Thus Tencer calls Hector 
a mad dog :— 

Toutov J'ou Wva/Aai Ba.\\iliv xvva \vs-a-n T«pa. — Hiad } lib. viii, V. 299. 

At Argos there was anciently an annual festival, called Cyrocephantes, during 
which, all the dogs that were running at large were killed. — Gorrcy, Sur la Rage. 
Journ. de Medecine, t. xiii, p. 93. 

t De Morb. Acut., p. 206, edit. 1722, as quoted by Van Swieten. 

% Callisen in Collect. Societ. Med.Havn., vol. i, ob. 32. Gruner's Almanach fair 
Aerzte, 1786, p. 184. Salzb. Med. Chir. Zeitung, 1795, b. iii ; p. 80. 



136 HYDROPHOBIA. 

of the year ; yet in some extremely warm and cold countries, this 
disease is said to be entirely unknown, or, at most, exceedingly un- 
common. 

In South America, Egypt,* Syria, the West Indies, Sweden, and 
Kamschatka,t hydrophobia, we are told, has been rarely if ever 
known to occur. Its spontaneous occurrence has also been thought 
to be particularly favoured by certain occult atmospheric constitu- 
tions; and this opinion is countenanced .by the fact that the disease 
has been known to occur at certain times and places in an epidemic 
manner.f Besides these presumed occasional or predisposing causes 
of hydrophobia, it has been alleged that putrid food, the protracted 
want of food and drink, unsatisfied venereal passion,§ and violent 
rage, are capable of originating this affection. Dr. Mease states that 
a number of dogs fed upon the carcases of horses that were left 
unburied near this city, and that many of them soon afterwards be- 
came affected with rabies. Rougemont relates similar examples of 
the apparent generation of this affection by putrid animal food. On 
the other hand, however, it has been observed that the dogs that 
crowd the streets of Constantinople feed almost exclusively on putrid 
animal substances, and yet hydrophobia is said to be almost wholly 
unknown at that place. " Putridity," says Dr. Good, "is perhaps 
the ordinary state in which dogs and cats obtain the offal, on which 
for the most part they feed : they show no disgust to it, and it offers 
a cause far too general for the purpose." With regard to the want 
of food and drink, as a cause of hydrophobia, Richter states, that in 
hot climates dogs have been known to perish for want of water, 
without having been seized with rabies. Direct experiments, too, 
have been made by confining dogs, both during very warm and 
cold seasons, and allowing them nothing but water without food, or 
salted and putrid meats, but no drink, without any of them becoming 
affected with this disease. || 

It is nevertheless probable that these causes, though not of them- 
selves capable of producing this disease, co-operate often with other 
influences in exciting its development. With regard to the tendency 
of violent rage to impart properties to the saliva of certain animals, 
capable of producing affections very similar, or as some assert, iden- 
tical with hydrophobia, many confirmatory observations are extant. 
Lister mentions an instance of fatal hydrophobia produced by the 
bite of an enraged dog,1F and similar cases are related by Dr. Park- 
inson and Linguet.** The bite of an enraged cat, also, has been 
known to give rise to fatal rabies in the human species. Rossi gives 

* Le Cointre, Journ. de Med., torn. vi ; p. 265, as quoted by Richter. 
f LangsdorPs Reisen., b. ii, p. 443. 

% Fehr. Etwas Ueber d. Hundswuth. Mease on Hydrophobia. 
$ Hildenbrand, Eein Wink zur Naehern Kermtniss u. Heilung d. Hundswuth, 
p. 4. 

II Ribbe. Natur. u. Medic. Geschicte der Hundswuth Krankheit. 

IT Tract, de Quibusd. Morb. Chronic, p. 43. 

** Journ. Politique, No. 1775, quoted by Richter. 



HYDROPHOBIA. 137 

an account of three cases of this kind.* Weikard states that a wo- 
man, n separating two fighting fowls, was bit by one of them, from 
which she became affected with fatal hydrophobia ;t and Le Cat 
mentions a similar event from the bite of an enraged duck.f The 
instances in which affections simulating hydrophobia have arisen 
from the bite of infuriated men, are by no means very rare. Van 
Swieten mentions a case of this kind,§ and other examples are re- 
lated by Weikard, Meekreen, Wolff, and Zacutus Lusitanus, as cases 
of genuine rabies. 

It is not improbable, however, that many of the reputed cases of 
hydrophobia, said to have arisen from injuries of this kind, were in 
reality peculiar forms of tetanic affections ; for the dread of water, 
which has been generally regarded as pathognomonic of rabies, has 
been frequently known to occur in cases unequivocally tetanic. 

The contagion of rabies belongs to the palpable or fixed morbid 
animal passions ; and does not admit of being diffused in the atmo- 
sphere — at least not in such a state as to retain its power of affecting. 
It would seem, however, to retain the power of affecting the system 
a very long time after it is generated. Cases are related in which 
the saliva of hydrophobic patients adhering to clothes, has given rise 
to the disease in persons who afterwards were employed to clean or 
mend them. Richter mentions the case of a woman who became 
affected with rabies in consequence of having mended a garment that 
was torn by the bite of a rabid dog.|| 

The period which intervenes between the insertion of the conta- 
gion of rabies and the commencement of the disease, is exceedingly 
various. It very rarely appears before the end of the third week, 
and in some instances the contagion remains dormant for six, nine, 
or even twelve months before its effects are manifested. From forty 
to sixty days may be regarded as by far the most common latent 
period of this contagion. Dr. Dickson states, that of seventeen per- 
sons who were bitten by the same dog, ten became affected with 
the disease at different periods from the fifteenth to the sixty-eighth 
day after the infliction of the bites.1T Instances, indeed, have been 
noticed, in which the disease came on as early as twenty-four hours 
after the bite of a rabid dog ; and Boudot mentions a case which 
supervened during the first night.** It is exceeding doubtful, how- 
ever, whether these cases were truly hydrophobic. The alarm 
occasioned by the bite of a rabid dog, may of itself be sufficient to 
cause spasmodic and nervous symptoms, simulating this disease, in 
persons of nervous temperaments. Authors, moreover, mention 
cases which did not supervene until several years after receiving the 

* Turiner Med. Abhand., 1802. 
t Philosoph. Arzt. s. iv, p. 186, quoted by Richter. 
X Recueil Periodique, ii, p. 90. 
$ Commentaries, $ 1130. 
" || Specielle Therapie, bd. viii, p. 378. 
^[ Med. Observ. and Inquiries, vol. iii, art. 34. 
** Eesais Antihydrophobique, 1771, p. 121— Richter. 



138 HYDROPHOBIA. 

hydrophobic contagion ; but the instances which are related as 
having occurred eighteen, twenty, and even forty* years after the 
insertion of the virus, require an effort of faith which few, I presume, 
are willing to exercise. There is, however, a very remarkable and 
well authenticated case related, of a woman who had been bitten by 
a mad dog, and in whom the wounded part inflamed and broke open 
every spring for eighteen years in succession. In the spring of the 
nineteenth year, the part became red and painful, without opening, 
and the immediate consequence was furious mania, with an insur- 
mountable horror of water. By the application of blisters to the 
affected part, blood-letting, and mercurial purgatives, she was cured.t 

Without doubt, however, the occurrence of this affection after the 
infliction of a bite from a rabid animal, may be promoted by the 
alarm and mental anxiety which an accident of this kind always 
excites to a greater or less degree. It would appear also that violent 
anger or vehement mental emotions, of every kind, and from what- 
ever cause they may arise, have no inconsiderable tendency to hasten 
the occurrence of this affection after its contagion has been intro- 
duced into the system. Observation would seem to show, too, that 
high atmospheric temperature has a similar tendency of promoting 
the activity of this contagion. It is said that the disease almost inva- 
riably comes on much earlier in hot climates than in the temperate 
latitudes. Richter mentions the free use of spirituous drinks and 
inordinate venereal indulgences, as causes capable of hastening the 
supervention of the disease.} Several very striking examples, illus- 
trative of the influence of the latter cause in this way, are mentioned 
by Rougemont. It is a fortunate circumstance, that the bite of a 
rabid animal is by no means generally followed by hydrophobia. 
The predisposition to the morbific influence of this contagion does 
not appear to be very strong in the human species ; and in many 
instances an entire insusceptibility seems to exist to its operation. 
It is from this cause, in part, at least, that we sometimes find only 
one or two out of a number of individuals bitten by the same dog, 
become rabid. Without doubt, too, the circumstances attending the 
infliction of the bite, often have a particular agency in hastening, 
retarding, or preventing the occurrence of the disease. When the 
animal bites through clothes, more especially woolens, the virus is 
probably often so completely wiped from the teeth before they pene- 
trate the skin, as to prevent infection. 

It has already been observed, that in the human subject hydro- 
phobia, or genuine rabies, appears to have but one origin ; namely, 
the application of the hydrophobic contagion to a raw or excoriated 
surface. It has, nevertheless, been asserted, that unequivocal rabies 
has occurred in the human species without the agency of a specific 
virus ; and Richter, as well as many other respectable authorities, 
are inclined to admit the possibility of such an occurrence. Mangor 

* Rougemont, loc. cit., p. 123. 

t Richter's Chirurg. Biblioth., b. v, p. 686. 

% Act. Reg. Soc. Med. Hav., vol. ii ? p. 408— Richter. 



HYDROPHOBIA. 139 

gives an account of an instance, where a melancholic man became 
affected with hydrophobia wholly unconnected with contagion, of 
which he died on the sixth day. His wife, who, during the course of 
the disease, frequently kissed him, also became affected with the dis- 
ease and died of it on the fifth day. 

Dr. Barth has related a very remarkable case of hydrophobia 
which was excited by cold. The patient, a man about forty years 
old, was subject to hemorrhoids, hypochondriasis and profuse sweat- 
ing of the feet. He bathed his feet in cold water, and in a few 
hours afterwards was seized with violent general spasms of the 
clonic character. The skin of the body was icy cold to the touch. 
The spasm occurred every eight or ten minutes, and continued about 
a minute. Among other things, the patient was ordered to drink 
warm elder tea ; " but the moment the patient attempted to drink, 
he was suddenly seized with a most violent spasm of the throat, 
and pharynx, and the fluid was immediately thrown out of the 
mouth; the eyes were convulsively distorted; the neck became fright- 
fully distended, and the head thrown backward ; the chest and the 
abdomen were raised from the bed while the hands and feet moved 
convulsively, and a hoarse sound, like that made by persons suffo- 
cating, was uttered by the patient." The disease yielded to sina- 
pisms, antispasmodic injections, warm pediluvia, and stimulating 
frictions. (Rut's Magaz., vol. 27, No. 1, 1828.) 

Symptomatic affections closely simulating hydrophobia are not 
very uncommon. A dread of water — exciting spasms and feelings 
of indescribable horror when attempts are made to drink — has been 
frequently noticed as an accidental occurrence in various diseases. 
Inflammation of the brain, uterus, and particularly of the heart, and 
of the cardiac extremity of the stomach, are most apt to become com- 
plicated with hydrophobic symptoms. Nervous affections, more 
especially hysteria and hypochondriasis, may also assume the pheno- 
mena of rabies; and instances are mentioned, in which mania and 
epileptic paroxysms have terminated in symptoms of hydrophobia.* 
The narcotic poisons— particularly stramonium, belladonna, and aco- 
nitum — have been known to produce spurious hydrophobia;! and 
it has been the consequence of suppressed menstruation by violent 
mental emotions. (Richter.) Malignant and other violent forms of 
fever are sometimes attended, in the advanced period of their course, 
with many of the characteristic symptoms of rabies. Schmucker 
relates a case of dropsy, in which the " water-dread" was for a time 
as strongly manifested as it usually is in genuine hydrophobia; and 
Frank saw an instance of its occurrence in diabetes.J In the last 
stage of pulmonary consumption, in hepatic obstructions, in jaundice, 
and in other chronic visceral affections, hydrophobic symptoms have 
been known to occur; and the occurrence of phenomena of this 
kind in tetanus is far from being uncommon. 

* Richter, Specielle Therapie. b. viii, p. 197. 
t Harles, Ueb. d. Behandl. d. Hundswuth, p. 72. 
% Epitom., &c, lib. v, p. i ; p. 54. 



140 HYDROPHOBIA 

Symptoms.— In nearly all instances of this affection, certain local 
and general premonitory symptoms occur for a longer or shorter 
period previous to the appearance of the characteristic phenomena 
of the disease. If the wound by which the contagion was communi- 
cated be not yet fully closed, it assumes a more or less livid appear- 
ance, with raised and inflamed edges, and begins to discharge a thin 
ichorous matter a few days before the accession of the proper hydro- 
phobic symptoms. Where cicatrization has been fully completed 
before the disease begins to develop itself, the cicatrix generally 
becomes slightly elevated, painful, inflamed, and finally often opens, 
forming an ill-looking ulcer with elevated borders, from which a thin, 
acrid and offensive matter is discharged. The pain in the affected 
part is often very severe; and sometimes gradually extends itself 
throughout the whole limb. It is said, that the pain in passing 
inwards from the part that was bitten, always proceeds along the 
course of the nerves towards their origin. Sometimes, however, little 
or no inflammation and pain in the injured part are noticed before the 
accession of the disease, with the exception usually of an occasional 
transient stinging sensation in the cicatrix. In some instances the 
patient experiences a peculiar torpor and numbness of the injured 
extremity. 

The general premonitory symptoms consist usually in lassitude, 
muscular prostration, indisposition to corporeal and mental exertion, 
flushes of heat alternating with transient sensations of chilliness, 
nausea, sometimes bilious vomiting, thirst, constipation, want of ap- 
petite, anxious respiration, and, in general, all the symptoms which 
usually precede the development of febrile diseases.* In some cases 
a constrictive sense of pain is felt in the extremities, passing gene- 
rally from the wounded part, and finally fixing itself in the head. 
(Richter.) The sleep is commonly disturbed by alarming dreams, 
and attended with slight spasms of particular muscles, and twitching 
of the tendons. The temper is almost invariably prominently affected 
shortly before the invasion of the disease. The patient is unusually 
reserved, suspicious, taciturn, and tormented with gloomy forebod- 
ings ; sometimes, though indeed seldom, he is animated and talk- 
ative. There is commonly an extreme degree of sensibility and 
repugnance to the impressions of cool air. In men, the desire for 
venery is often almost irresistible a short time before the disease 
comes on, and Hamilton states that the scrotum is usually very 
strongly, and, as it were, spasmodically contracted. 

These precursory symptoms sometimes continue for seven or eight 
days before the actual occurrence of the disease ; but their ordinary 
duration varies from two to four or five days. Occasionally, indeed, 
no premonitory symptoms whatever are noticed before the accession 
of the disease. 

The only symptom which is never wholly absent in this disease, 
as it affects the human species, is the extraordinary dread or horror 
of liquids — more especially of water. Patients labouring under 

* Richter, loc. cit., p. 129. 



HYDROPHOBIA. 141 

rabies may, indeed, sometimes experience a temporary abatement 
or even absence of this torturing symptom, but in all instances it 
occurs in a greater or less degree, and generally remains throughout 
the whole course of the malady. In general, the mere sight of 
liquids, or the sound of pouring water from one vessel into another, 
brings on violent suffocative spasms; and the attempt to swallow 
water or to bring it to the lips, commonly excites a degree of horror 
and agitation truly frightful. Even the sight of polished surfaces, 
as of a mirror, or the rustling sound of bed curtains, of currents of 
air, or of running water, will, in the more violent grades of the dis- 
ease, immediately renew the spasms and feeling of horror. Occa- 
sionally, however, this extraordinary horror is manifested only against 
water; for patients have been known to take small portions of other 
fluids, as of soups, milk, and wine, in a lukewarm state. The thirst 
is always extremely urgent, and though the suffering from this source 
is generally very great, the patient dares not attempt to swallow any 
liquids. The secretion of saliva is profuse, and from an inability to 
swallow it, the patient continually spits it out in every direction, 
"often desiring those around him to stand aside, as conscious that he 
might thereby injure them." During the whole course of the disease 
occasional remissions occur. Whilst these continue, the patient often 
appears calm, talks deliberately about his feelings or his affairs, and 
cautions those who are about him not to approach him too closely 
when under the paroxysm of madness, lest he should injure them. 
Notwithstanding this partial calm, there are always a peculiar wild- 
ness and appearance of alarm in the expression of the countenance : 
the motions are quick and hurried; the eyes cast about with an air 
of suspicion ; and if the patient attempts to lie down and obtain some 
rest, he usually soon starts up again with great agitation and anguish 
of feeling. During the exacerbations, the expression of the counte- 
nance is wild, furious, agitated, and agonized ; the eyes are blood- 
shot, sparkling, projecting, and expressive of rage and terror ; the 
muscles of the face, throat, chest, and sometimes the extremities, 
are thrown into spasms; respiration is interrupted or convulsive; 
the arms are thrown about; the lists clenched; the teeth violently 
gnashed; the mouth foaming; with an unconquerable disposition to 
bite every thing that comes within the patient's reach. In violent 
paroxysms, furious and maniacal raving occurs, attended often with 
an entire absence of consciousness. These paroxysms usually last 
from about fifteen to thirty minutes. Many patients, however, do 
not become furious or maniacal during the spasmodic exacerbations, 
and retain almost the full command of their mental powers, from 
the commencement to the fatal close of the malady. In some in- 
stances a tormenting degree of salacity is experienced during the 
intermissions, attended with continued painful erections, and occa- 
sional involuntary discharges of semen. Patients affected with rabies 
generally walk about through the room, or remain sitting up as long 
as their strength admits of this effort, for the horizontal posture is 
almost always borne with much difficulty. 
Hydrophobia is very rarely attended by distinct febrile symptoms, 



142 HYDROPHOBIA. 

except sometimes towards the conclusion of the disease. At first the 
pulse generally does not materially differ from its natural condition; 
but in the latter periods of the complaint it always becomes small, 
irregular, weak, and very frequent. The eyes are in general very 
sensible to light ; and the countenance is pale during the remissions, 
but turgid and flushed during the paroxysms. Some patients are 
from time to time affected with vomiting, attended with a burning 
heat in the pit of the stomach. The morbid sensibility to the impres- 
sions of low temperature, which occurs generally among the premo- 
nitory symptoms, often rises to an extreme degree during the course 
of the disease. Towards the termination of the malady, the tongue 
becomes rough, harsh, chapped, and often aphthous. The surface of 
the body is usually constricted and dry, the bowels constipated, and 
the blood drawn from a vein often dissolved and very fluid. (Richter.) 
The duration of hydrophobia is fortunately not long. Most patients 
die as early as the second or third day of the disease. It is rarely 
protracted beyond the fifth or sixth day ; although instances have 
occurred which did not terminate under fourteen or fifteen days. 

Post-mortem appearances. — The morbid phenomena, detected by 
dissection, in those who die of hydrophobia, are extremely various 
in different cases, and throw but very little or no light on the true 
nature of this affection. It is said that the process of decomposition 
often commences very early after death, and proceeds with great 
rapidity.* The surface of the body is usually of livid redness, and 
the muscles, and particularly the tendons, are unusually rigid. Strong 
vascular congestion of the meninges and brain, with serous, or sero- 
sanguineous effusion between the membranes and into the ventricles, 
are among the most common phenomena. In some instances, the 
brain has been found unusually firm and dry, (Morgagni;) in others 
extremely soft. The mucous membrane of the mouth and fauces, and 
particularly about the glottis, is usually inflamed, and sometimes con- 
siderably tumefied or oedematous. In some instances, however, these 
parts did not exhibit any material deviation from their natural con- 
dition, (Morgagni, Vaughan;) in others, instead of inflammation, the 
mucous membrane of the mouth and fauces was of a rose-red colour, 
with a varicose dilatation of some of its blood-vessels.t The cervical 
ganglia have been found inflamed. The lungs are often greatly en- 
gorged with blood, and their mucous membrane irritated or inflamed. 
In some cases the mucous tissue of the stomach and bowels exhibits 
evident marks of previous inflammation ; and the same phenomena 
are occasionally met with in one or more of the abdominal viscera. 
Metzler, Benedict, Gherardini, and Autenreith have found the nerves 
leading from the wounded part manifestly inflamed to a considerable 
extent of their course. It must be observed, however, that many in- 
stances have been reported, in which scarcely any morbid appearances 
whatever were detected on post-mortem examination. 

* Sauvages— De la Rage. Morgagni; De Sedeb. et Caus. Morbor., lib. ii, art. 
xix. 
t Krukenberg, as quoted by Richter. 



HYDROPHOBIA. 143 

With regard to the proximate cause or pathology of hydrophobia, 
there is but very little, or nothing, known of a satisfactory character. 
The very numerous opinions that have been expressed upon this sub- 
ject, resolve themselves into : 1, those which regard the sanguiferous 
system as the primary location of the disease, viewing it as essen- 
tially an inflammatory affection: and 2, those which place the essential 
irritation exclusively in the nervous system. The general sentiment, 
at present, is in favour of the latter doctrine; but there exists nothing 
beyond plausible conjecture and hypothesis, with regard to the parti- 
cular character of the nervous affection, or the portion of the nervous 
system chiefly implicated. Without entering into any discussion on 
this obscure subject, it may be observed, that although the essential 
phenomena of the disease point unequivocally to a morbid condition 
of the brain and nerves, we have equally conclusive evidence that 
the arterial system is in a state of morbid excitement ; for without 
diseased vascular action there could be no hydrophobic virus secreted. 
The opinion, however, that it is an inflammatory affection, is certainly 
not sustained by the symptoms of the disease. That local inflam- 
mation should sometimes occur during the progress of the malady, is 
indeed to be expected ; but even this occurrence does not appear to be 
so common as has been asserted; for many of the repeated examples of 
local inflammation, were probably merely instances of strong vascular 
injection or engorgement, with its occasional consequent serous effu- 
sion, produced either during the course of the disease, or in articulo 
mortis. Rabies is, I presume, essentially a cerebral affection. The 
peculiar dread of liquids, the paroxysms of fury, or mental agitation, 
spasms, and general feelings of anguish and alarm, without any 
manifest febrile symptoms, all indicate that the disease is essentially 
connected with, or dependent on, a morbid excitement or condition of 
the brain, independently, it would seem, of diseased vascular action 
or phlogosis. 

Treatment. — After all that has been said and done in relation to 
the nature and remedial treatment of rabies, there is, perhaps, no 
other affection which is so decidedly beyond the control of all the 
resources of our art as this appalling malady. That it is essentially 
an incurable disease cannot indeed be affirmed ; for however unsuc- 
cessful the efforts of physicians may hitherto have been, there is 
certainly nothing in its characteristic phenomena, which should lead 
us to assert that it is necessarily fatal, or to abandon the hope that 
some mode of management or remedy may yet be discovered, capa- 
ble of arresting its progress. Indeed, unless we discredit the autho- 
rity or judgment of several physicians of good repute, we must admit 
that instances of genuine hydrophobia have been successfully sub- 
dued by remedial treatment. Unfortunately, however, such favour- 
able results have been so exceedingly rare, that they can scarcely 
sanction any expectations of advantage from remedial applications, 
after the disease has made its appearance. 

Our reliance must, therefore, be entirely placed in the prompt 
and energetic employment of prophylactic measures ; and for this 
purpose, local applications to the wound, with the view of prevent- 



144 HYDROPHOBIA. 

ing the absorption of the hydrophobic virus, are decidedly the most 
efficient remedies. 

As soon as possible after the infliction of the bite, the wound and 
surrounding surface should be carefully washed with warm, or, as 
Hunter recommends, cold water ; and immediate efforts made to pre- 
vent the further passage of the virus into the system. If the bite be 
of a character, and in a part which admits of its entire excision, this, 
if speedily done, affords undoubtedly the most certain protection 
against the occurrence of the disease.* 

If the bite be on the hand, particularly when the teeth of the animal 
have penetrated deeply between the bones, it will be best to ampu- 
tate : and this is especially proper if only the fingers are wounded. 
Some have preferred destroying the wounded part with the actual 
cautery, and there can be no doubt of the efficiency of this measure, 
if employed soon after the bite has been received. The free appli- 
cation of caustic potash may also be resorted to with success where 
the wound is superficial ; but where it has penetrated deeply, it can- 
not supply the place of excision, or the actual cautery. In slight 
wounds, the application of cupping glasses, as is recommended by 
Dr. Barry, for the purpose of arresting the effects of poisoned wounds, 
would, perhaps in most cases, be sufficient to prevent the occurrence 
of rabies. Dr. Good "strenuously recommends the immediate appli- 
cation of a tight ligature to the affected part, a short distance above 
the wound, if its situation will admit of it." 

Besides these local measures, which alone deserve our confidence, 
a vast variety of internal remedies have been recommended, with the 
view of counteracting the hydrophobic virus. Of all other diseases, 
indeed, rabies has afforded the widest scope for empiricism and char- 
latanry. Innumerable remedies have, at different times, been lauded 
as infallible preventives of this affection; but sad experience has 
hitherto nullified all these pretended specifics. 

The most celebrated of these remedies is belladonna. This arti- 
cle was first used by Mayerne. Munch asserts, that in 176 instances 
the occurrence of the disease was prevented by this medicine ;t and 

* [By a free excision of the wound after the bite of a rabid dog, I have pre- 
vented hydrophobia in every case to which I have been called before the access 
of a paroxysm. I pinch up the integuments as deeply as possible between the 
left thumb and fingers, and shave out all the parts around and below the wound, 
if it be a superficial one, and then dissect out the bottom, if it be a deep-seated 
one. A cupping glass over the wound and a ligature above it will then promote 
a sufficient hemorrhage to discharge all the virus. Under this treatment, Mr. 
Robeno, a tailor, in Southwark, escaped after two severe bites on the outside of 
the calf of one of his legs — when a woman, who had been bitten just before by 
the same dog in the same street on one of her hands, was seized a week after- 
wards with a fatal hydrophobia. My friends, the two Dr. Klapps, treated her by 
the ligature and caustic, and also by the plentiful use of the decoction of Scutel- 
laria. — Mc] 

t Dissert, de Belladonna Efficaci in Rabie Canina Remedio. 



HYDROPHOBIA. 145 

we have the authority of Stark, Jahn, Bucholz,* Sauter,t and Hufe- 
]and,J in favour of its prophylactic powers against this affection. 
Anagalis arvensis. — This is one of the oldest remedies for the pre- 
vention of rabies. Both Galen and Aetius recommend it for this 
purpose. It formed the basis of several celebrated nostrums, for- 
merly vended in this country; and its powers have been particularly 
extolled by Ravenstein, Cartheuser.§ Chabert, Ribbe, Stoeller, and 
other writers on this disease. Lichen cenereus constituted the prin- 
cipal ingredient in the pulvis antilyssits of Dambiere.|| The cele- 
brated Mead asserts, that in more than one hundred instances, he 
prevented the disease by this remedy. 

The water plantain (alisma plantaqo) has, of late years, attracted 
much attention as a prophylactic remedy in this affection. It was 
first employed in Russia ; and many respectable names might be cited 
in favour of its powers in this respect. The powdered root or bulb 
is given in doses of from a scruple to a drachm once daily. The 
root, it is said, should be collected about the latter end of August. 
The Scutellaria lateriflora is fresh in the recollection of every one, 
as a highly boasted preventive of this malady. Like other articles of 
this kind it has had its day ; and there are probably now very few, 
if any, physicians, who would place the least reliance on its powers 
— as it certainly does not appear to deserve any confidence what- 
ever. % Boerhaave, Erpenbeck, Moneta, and others, speak highly 
in favour of the internal and external use of vinegar as a preventive 
in this affection. A tablespoonful of strong vinegar is to be given 
three or four times daily for several weeks. Much has also been 
said in praise of the internal use of canthandes as a protection 
against rabies. This remedy is mentioned by Rhazes : and among 
the moderns, Werlhof,** Bucholz, and particularly Rust,tf have 

* Hufeland's Journal, bd. v, p. 378. 

t Ibid., bd. vi, p. 679. 

t Ibid., bd. xvi, p. 113. 

$ Fundamenta Materia Medica. 

II Two drachms of this substance, with half an ounce of black pepper, was 
given every morning for four days in succession, in a cup of warm milk; and 
the patient directed to use the warm bath daily for a month afterwards. 

If Besides the vegetable substances mentioned in the text, the following have 
been employed, and especially recommended, for the prevention of rabies. Rad. 
Cynosbati, (Van Swieten ;) Celtis australis ; phytolacca decandra, (Harles :) ecltis 
ambralis. (Hufeland's Journal, bd. xxxii ;) valerian, (Bouteille:) nux vomica, (The- 
besius, Leidenfrost ;) faba St. Ignatii; datura stramonium, (Mease, Cooper, Harles, 
Brera, Hannemann ;) tobacco, (Barton's Med. and Phys. Journ., vol. ii, p. 122;) 
lycopodium clavatum, (Hildebrand :) camphor, (Sehmucker :) gentiana pneumo- 
nanthe; hypericum dubium ; thalictrum flavum; paris quadrifolia; cichorium 
intybus; genista tinctoria; ranunculus sceleratus; campanula patula, and glome- 
rata ; polypodium bistorta ; mercurialis perennis ; &c. 
** Opera Omnia, part iii, p. 699. 

ft Ueber d. durch den biss ein. hundes veranlaste Wasserscheu — in dessen 
Magazin. f. d. gesammte heilkunde, 1816, b. i, p. 97. 
VOL. II. 11 



146 HYDROPHOBIA. 

spoken decidedly in its favour. Axter, a G erman surgeon of deserved 
celebrity, states, that he never knew the internal administration of 
cantharides to fail in preventing rabies. As principal surgeon of the 
general hospital at Vienna, he had frequent opportunities of treating 
cases of this kind, and his opinion, as Richter observes, is entitled 
to great weight, as it is founded on a long course of very exten- 
sive experience. He gives one grain of the powdered cantharides 
daily in union with tartar emetic, for five or six days in succession, 
and keeps the wound open for six weeks, by vesicatories and pow- 
dered cantharides.* 

No remedy has had more repute as a preventive of hydrophobia, 
than mercury. Astruc, Sauvages, Van Swieten, De Haen, Tissot, 
Portal, and Werlhof, regard this article as the most certain prophy- 
lactic we possess against rabies. Many examples, illustrative of its 
good effects, have been reported ; but the instances in which saliva- 
tion has failed to prevent the occurrence of the disease, are, perhaps, 
no less numerous, and it is now generally regarded as entitled to but 
very little confidence in this respect.t Within the last few years, 
M. Coster, a French surgeon, has published some statements which 
would seem to show that chlorine has the power of decomposing and 
destroying the hydrophobic virus. Two tablespoonfuls of chloruret 
of lime are to be dissolved in half a pint of water, with which the 
bitten part must be frequently bathed. It is said to have proved 
successful when applied six hours after the bite was received. 

Cold bathing or affusion is recommended by Celsus and Coelius 
Arelianus, as a powerful prophylactic means in this affection. Cases 
of its successful application are mentioned by Van Swieten, Saba- 
tier, Andry, and others ; and it can scarcely be doubted, that by its 
invigorating and alterative effects, it is, at least, a very proper auxi- 
liary to whatever other measures may be employed to obviate th« 
disease. % 

Besides the remedies already mentioned, a vast number of nos- 
trums and mixtures have had a temporary reputation as prophylac- 
tics against rabies. These, however, have all passed into merited 
neglect ; and at present, there is perhaps no article of this kind that 
is countenanced by any respectable member of the profession. 

Most of the foregoing remedies have also been employed for the 
purpose of curing the disease after it has actually made its appear- 
ance. Stark asserts, that he cured two cases of hydrophobia by the 
exhibition of belladonna in large doses ; and Sauter relates several 
remarkable instances which yielded to the powers of this remedy.! 
He gave it in doses of from eight to twelve grains of the powdered 

* Richter's Specielle Therapie, b. viii, p. 278. 

t The carbonate of ammonia (Martinet, Darluc;) musk, (Dalby, Nugent, Tissot, 
Gmelin:) acetate of copper, (Leib.:) copper filirgs, (Cothenius;) phosphorus, (Zinke;) 
arsenic, (Lond. Med. and Phys. Joura, 1789.) have all been recommended fot 
their prophylactic powers in this affection. 

t Hufeland's Journal, bd. xi, p. 3. 



HYDROPHOBIA. 147 

root every forty-eight hours. Shallern also cured a case of com- 
pletely developed rabies by the use of this narcotic* A case is re- 
lated in Hufeland's Journal, (b. 44,) which was successfully treated 
by a combination of anagalis, mar urn veritm, and basilicum; and 
the celebrated Vogel asserts, that he cured several well-marked cases 
with a decoction of the anagalis.t According to Martinet, the liquid 
caustic ammonia has arrested the disease in four instances. He gave 
sixty drops at. first, and afterwards fifteen drops every two hours, 
with a few ounces of a strong decoction of cinchona every four 
hours.J Rust states, that he succeeded in subduing the disease, in 
one instance, with large and repeated doses of cantharides;§ and 
Axter prevented the full development of the disease, after unequi- 
vocal symptoms of its attack had already made their appearance. 
The meloe majalis was used successfully by Kortum ; and Selle em- 
ployed them with decided benefit. The very free use of mercurial 
remedies— particularly in the form of frictions, in conjunction with 
baths and musk — is said to have been employed with success in 
some instances of rabies, (Callisen, Rougemont.) Dr. Munckly has 
related a case which yielded under the influence of a free mercurial 
salivation. || Olive oil, both externally and internally employed, is 
said to have removed this affection. 

Both Celsus and Ccelius Arelianus recommended frictions with 
warm oil as an efficient remedy in rabies. Vater has adduced facts 
illustrative of its curative powers in this affection,! and Shadwell, an 
English physician, has given an account of a case, which would ap- 
pear to have yielded to the internal and external use of sweet oil.** 
The cold plunging-bath, or copious affusions, is mentioned by Van 
Swieten, as having succeeded in arresting the progress of rabies jtt 
and Morgagni refers to similar instances of success ; although he 
himself saw an instance in which the patient died almost instanta- 
neously on being plunged into cold water. Dr. Arnell has related 
a case in which pumpmg for two hours and a half on the patient, 
was decidedly beneficial. it 

Copious blood-letting also has been much insisted on as a remedy 
in hydrophobia, and there was not wanting well-authenticated in- 
stances of its beneficial effects. Pourpart asserts that prompt and 
very copious abstractions of blood, so as to induce complete syncope, 

* Bernstein's Neu. Beitraeg., b. ii. See also Hecker's Annal d. gesammt. Med., 
bd. ii, p. 90 — quoted by Richter. 

t Praelectiones. 

% Richter's Specielle Therapie, bd. viii, p. 320. 

k Salzb. Med. Zeit., 1811, No. 76. 

|| Med. Transact., vol. xi, art. xii. 

H Programma de 01. Olivar. efficacia contra morsum canis rabida — as quoted 
by Richter. 

** Mem. of the Med. Society of London, vol. hi. 

ft Commentaries, vol. iii, p. 576. 

XX Med. Recorder, 1824. 



148 HYDROPHOBIA. 

has effectually arrested the disease;* and Dr. Hartley cured a case 
by taking away 120 ounces of blood in the course of a tew days.t 
Iti one case, blood was drawn to the extent of producing syncope 
during each paroxysm of the rabies, with the happiest effect^ and 
Dr. Russell states that a vein was opened in a young women affected 
with rabies, and suffered to bleed until she fell down in a state of 
syncope, with the effect of arresting the disease.§ Dr. Rush was a 
strenuous advocate for copious venesection in hydrophobia. We may 
also cite the cases reported by Burton, Grisley, Willoughby,and par- 
ticularly the interesting instances related by Tymon,|| SchoolbreedJ 
Wynne,** Goeden,tt as striking examples of the occasional good 
effects of decisive bleeding in this affection. In Dr. Tymon's case, 
blood was at once drawn until the pulse could be scarcely felt, and 
100 drops of laudanum administered, with injections of 300 drops of 
laudanum every two hours. On the following day two grains of 
opium with four grains of calomel were administered every two hours, 
and continued to the sixth day, when ptyalism, with gradual subsi- 
dence of the disease, occurred. In the case reported by Dr. School- 
breed, about fifty ounces of blood were drawn from a large orifice at 
once. Syncope ensued, and the disease was for a time manifestly 
moderated. As the symptoms appeared to increase again, he was 
once more bled to fainting, which had the effect of completely sub- 
duing the water dread, and paroxysms of fury. Calomel and opium 
were given for some time, under the use of which the patient's health 
was re-established. Parry, nevertheless, considers these two cases as 
very equivocal instances of rabies; but the histories given of them 
leave us little or no room to doubt that they were genuine instances 
of hydrophobia. A number of cases have indeed been reported, in 
which the most energetic depletion did not produce the slightest im- 
pression on the disease. Dupuytren, Magendie, Breschet,JJ Bellingen, 
Horn, Marshal, Olbers, Hufeland, Rust, and others, state that they 
have not derived the least advantage from this measure. 

In conclusion, it is proper to state that, among the prophylactic 
measures, a regulated regimen, gentle exercise, an attention to the 
regular action of the bowels, and particularly avoiding violent mental 
emotions, overheating, violent exercise, as well as the influence of 
sudden atmospheric vicissitudes, and all kinds of stimulating drinks, 
are all important observances. 

* Histoire de l'Academie des Sciences, Paris, 1699. 

t Philosophical Transactions, 1738, 

t Gentleman's Magazine, Sept., 1752. 

$ Historical Magazine for 1792. 

II Edin. Med. and Surg. Journ., 1813, p. 22. 

TI Tbid., Jan., 1813, p. 30. 

** Med. and Phys. Journ., Nov., 1814. 

tt Hufeland's Journal, bd. xlii, p. 64. 

$$ Orfila, Toxicology, &c. 



MENTAL DERANGEMENT 149 



CHAPTER II. 

CHRONIC NERVOUS AFFECTIONS, IN WHICH INTELLECTUAL AND MORAL 
FACULTIES ARE DISORDERED. 

Sect. I. — Mental Derangement. 

Without stopping to inquire into the nature and laws of the hu- 
man understanding, or into its mysterious connection with the animal 
body, it will be enough for our purpose to observe, that all the per- 
ceptions of the mind, and consequently all the materials upon which 
alone it can exert and manifest its powers, are derived from impres- 
sions communicated to it through the medium of the body. It is here 
assumed, therefore, that without a morbid condition of those parts of 
the organization which receive and convey to the mind the elements 
of thought, and which thus constitute, as it were, the connecting link 
between intellect and the external world, insanity can have no ex- 
istence. 

Pathologists have endeavoured to ascertain the seat of the primary 
irritation of insanity; but the observations we have upon this point 
are as yet vague and unsatisfactory. Pinel maintains that the pri- 
mary seat of mental derangement is located in the epigastric region, 
whence the morbid irritation is propagated to the common sensoriuin. 
This is an old doctrine. Aretaeus* observes, " verum praecipuae furo- 
ris et melancholias sedes viscera sunt;" and it is indeed extremely 
probable, that in some instances, at least, the primary source of insanity 
consists in an irritation seated within the abdomen. The intimate 
sympathetic relation that subsists between the brain and the chylo- 
poietic viscera, is well known. A derangement in the functions of 
the one seldom fails to induce a corresponding disorder in the func- 
tions of the other. Sudden fear, or disappointment, or violent anger 
dissipates in a moment the keenest appetite ; and a disordered state 
o(' the digestive organs is no less apt to give rise to torpor of intellect, 
irresolution, despondency, and waywardness of temper. In whatever 
part of the body the primary irritation may be located, it must, how- 
ever, always be communicated to the brain, the mental organ, before 
the intellectual faculties can be deranged; and the proximate cause 
of insanity may therefore be regarded, as consisting in morbid cere- 
bral excitement, existing either as a sympathetic or primary affection. 
As the musician cannot draw melodious tones from an instrument that 
is defective, so the mind cannot produce harmonious and correct 
thought, when its organ, the brain, is in a state of morbid excite- 
ment; and it matters not whether this morbid condition be the result 

* De Caus. et Sign. Morb. Diut., lib. i, c. 37. 



150 MENTAL DERANGEMENT. 

of causes acting immediately on the brain, or of such as primarily 
affect other organs, whose sympathetic relations are such as to throw 
the irritation upon the common sensorium. 

What is the nature of the cerebral affection upon which the derange- 
ment of the intellectual faculties immediately depends? According 
to Dr. Rush, it consists in a morbid action on the blood-vessels of the 
brain ; whilst others view it as simply a state of nervous or cerebral 
irritation, without any necessary connection with disordered vascular 
excitement. That the capillary blood-vessels of the brain are in a 
state of morbid excitement in perhaps all instances of mental derange- 
ment, is, I think, extremely probable. Whether, however, this irre- 
gular vascular action in the brain constitutes an essential condition of 
insanity, or whether it be only one of the consequences of the pri- 
mary cerebral irritation, may admit of some doubt. No nervous 
irritation can be long maintained without inducing diseased action in 
the blood-vessels. However this may be, insanity, doubtless, always 
depends on disordered function of the brain; and the deranged cerebral 
function is probably invariably the result of morbid action of both 
the medullary structure and the blood-vessels of this organ. 

Cat(ses. — The predisposition to insanity is, in many instances, very 
evidently dependent on an hereditary peculiarity of organization. 
Dr. Rush mentions several very striking examples of this kind.* 
Esquirol asserts, that, according to his own observations, one-half of 
the cases of insanity which occur among the wealthy, and at least 
one-sixth of those among the poor, depend on hereditary predisposi- 
tion ;t and according to a tabular statement given by Dr. Casper,} 
it appears that in the different hospitals in Paris, the proportion of 
cases depending on hereditary predisposition, is to the whole number 
as about 1 to 4|. Esquirol states that he has met with an instance 
of seven sisters and brothers out of one family having been affected 
with insanity ;§ and Haslam mentions ten families, in every one of 
which, several cases of mental derangement occurred. || Dr. Rush ob- 
serves, that the following, among other peculiarities, attend this disease, 
where the predisposition to it is hereditary : "1, weaker exciting causes 
develop the disease than where the predisposition to it has been 
acquired ; 2, it is apt to come on about the same period of life at 
which it appeared in the patient's ancestors ; 3, children bom previous, 
are less apt to become insane, than such as are born after the occur- 
rence of mania in their parents ; 4, in some instances of families in 
which madness has existed, the disease passes by the understanding 
in their posterity, and appears in great strength, and eccentricity of 
memory and of the passions, or in great perversion of their moral 
faculties." 

The liability to mental derangement is greatest between the twen- 

* On the Diseases of the Mind, second edition, p. 48. 

t Diet, des Sciences Medic, Art. Folie. 

+ Characteristic der Franzosischen Medicine, von J. L. Casper, p. 380. 

$ Loc. citat. 

II Observations on Madness and Melancholy, p. 231. 



MENTAL DERANGEMENT. 



151 



tieth and fortieth years of age ; and according to the observations of 
Esquirol, more particularly between the ages of twenty-five and 
thirty. The following tabular summary in relation to this point, 
drawn up by Dr. Casper from the observations of Pinel, Esquirol, 
Haslam, and others,* shows that from the thirtieth to the fortieth 
years of age, the occurrence of insanity is decidedly more common 
than during any other equal period of life. During childhood, or 
before the age of puberty, mania occurs very rarely. Instances are 
nevertheless mentioned, in which insanity appeared at a very early 
period of life. Dr. Rush saw two cases in children only two years 
old ; in one instance it appeared during the seventh, and in another 
during the eleventh year of age. Haslam also relates an instance 
which occurred in a girl only four years old ; in another instance the 
disease came on in the seventh, and in a third one about the tenth 
year of age. 

Old age is almost equally unfavourable to the occurrence of mania. 
Dr. Rush states that he has met with but four instances in which the 
disease came on after the sixtieth year of age. It has moreover been 
observed, that maniacs rarely live to a very protracted age. Dr. 
Casper, however, mentions a very remarkable exception to this 
general fact. A coloured woman, he says, who had laboured under 
mental derangement for upwards of eighty years, was brought into 
the Hospital Salpetriere in a state of raving insanity, at the very 
advanced age of one hundred and seventeen years A 

In relation to the relative frequency of insanity in the two sexes, 
it is pretty generally admitted that it is more common in females 
than in males. Haslam gives a statement, from which it appears, 
that during a period of forty-six years, there were 4832 female, and 
only 4012 male lunatics admitted into the Bethlehem Hospital in 
London. It appears, however, from the inquiries of Dr. Casper, that 
the proportion of female over male lunatics is much greater in France 
than in England. 

It is worthy of notice that the predisposition to mental derange- 
ment is very generally connected with black, or dark brown hair, 



Age. 



Pinel, in the Bicetre, from 1784 — 94 

(males) admitted. 
Esquirol, in Salpetriere, from 1811 — 14 

(females) admitted, 
Haslam, Bethlehem hospital, from 1784 

— 94 admitted, 
Esquirol's private institution, 1811 — 14 

(wealthy patients,) 
Hospital of Retreat at York, 1796—1811 

(Quakers,) 



t Med. Chir. Rev., Sept., 1820, p. 25. 



15 


20 


30 


40 


50 


60 


70 


to 


to 


to 


to 


to 


to 


to 


20 


30 


40 


50 


60 


70 


80 


65 


3 39 


380 


236 


130 


51 





171 


135 


403 


205 


115 


66 


23 


113 


488 


527 


362 


143 


131 








150 


78 


30 


46 


15 


8 


8 


44 


28 


28 


27 


9 


4 


357 


1156 


1416 


861 


461 


272 


35 



152 



MENTAL DERANGEMENT. 



and a dark complexion. Esquirol states that out of two hundred 
and twenty-seven females affected with mania, one hundred and 
fifty-two had dark, thirty-nine fair, and thirty-six gray hair. Dr. 
Rush informs us, that of nearly seventy patients in the Pennsylvania 
Hospital, who were examined with a reference to this fact, in the 
year 1810, "all except one had dark-coloured hair." In some re- 
gions, menial diseases are manifestly endemic. This is the case with 
the Cretins in many of the gorges of the mountainous districts of 
Europe : and it would appear that this disease is found only where 
the soil is calcareous* 

The exciting causes of mental derangement are usually divided 
into the moral and physical— or into those which affect the animal 
organization through the medium of the mind, and those which act 
directly upon the body.t Of the former kind are — intense mental 

* Med. Chir. Rev., Sept., 1820, p. 25. 



PHYSICAL CAUSES. 



Hereditary, 

Pregnancy, ------- 

Epilepsy, ....... 

Suppressed Menstruation, - 

Puerperal State, ...... 

Old Age, 

Coup de soleil, 

Injuries of the Head, 

Congenital, 

Fever, -------- 

Apoplexy, 

Malformation of the Skull, .... 

Fire and other injurious Substances, 

Syphilis, 

Imprudent use of Mercury, -.-.-- 

Onanism, ....... 

Intoxication, 

Worms, 

Suppressed Cutaneous Diseases, ... 

Suppressed Haemorrhoids, .... 

MORAL CAUSES. 

Grief, 

Unfortunate Love, ...... 

Fanaticism, 

Fright, 

Jealousy, ....... 

Anger, 

Distress and Want, ------ 

Mortified Pride, 

Disappointed Ambition, -•-,-•-.- 
Intense and Protracted Study, - - - - 

Misanthropy, 

Vives Revolutions d'esprit, .... 
Political Causes, (a) 

(a) Casper, loc. cit., p. 380. 



Salpe there, 

• n the years 
1811-12. 


Esquirol's 

private hos. 
1811-12. 


105 


150 


11 


4 


11 


2 


55 


19 


52 


21 


60 


4 


12 


4 


14 


4 


13 


12 


60 


10 


8 


1 


14 


18 


24 


4 


105 


31 


46 


25 ! 


8 


1 


38 


8 


18 


14 


16 




77 


14 


1 


16 




12 




13 




2 


14 


31 



g2 
.2 o 



118 

36 

69 
157 

9 

27 



21 
106 



99 
37 
55 



116 

78 
49 

58 



MENTAL DERANGEMENT. 153 

application to one subject; violent rage ; jealousy; excessive joy; 
sorrow; hatred; terror; surprise; fanaticism; unrestrained imagina- 
tion; disappointed love, ambition, or vanity ; mortified pride; cha- 
grin; protracted mental depression ; and religious enthusiasm. From 
the preceding table it would appear that grief, distress, want, and 
disappointed love, are decidedly the most common exciting causes 
of insanity. Mr. Pinel observes, that a frequent and powerful 
source of insanity is the struggle between the principles of religion, 
morality, and education, on the one hand, and the urgent influence 
of the natural propensities and the passions on the other. 

Among the causes that act directly on the body, the following are 
the principal ; inanition from excessive hemorrhage or defect of food ; 
intoxication ; suppressed habitual discharges, particularly the cata- 
menial; onanism; inordinate venereal indulgence ; restrained or un- 
satisfied venereal passion ; worms in the alimentary canal ; blows 
or falls on the head; apoplexy; epilepsy; repercussion of chronic 
cutaneous eruptions ; pregnancy ; parturition ; the puerperal state ; 
syphilis; intense pain ; very low and high atmospheric temperature ; 
an inordinate or improper use of mercury ; various narcotic poisons; 
atmospheric influences; gastro-intestinal irritation ; the healing up of 
old ulcers ; and the various forms of acute diseases. 

From the table given above, it appears that verminous irritation is 
no uncommon cause of insanity. Dr. Casper informs us that Esquirol 
stated in his lectures, that he had known eleven persons cured of 
mania after the expulsion of a large number of lumbrici by the use of 
anthelmintics. Mania appears indeed often unequivocally connected 
with intestinal irritation. The observations of Dr. E. Percival and 
Dr. Prichard on what the latter terms enteric mania, may be con- 
sulted with much advantage. In these cases the morbid condition 
of the alimentary canal is generally decidedly marked. The gastric, 
biliary, and intestinal secretions are depraved ; the bowels are loaded, 
tumid, flatulent, and much constipated ; sharp and transient pains are 
felt in the abdomen ; the tongue, fauces, and velum pendulum, be- 
come red, injected, and tender ; the appetite is irregular, or there is 
much aversion to all kinds of food. The puerperal state too is a fre- 
quent exciting cause of mental derangement. According to Haslam, 
eighty-four out of sixteen hundred and sixty-four maniacal patients 
admitted into Bethlehem hospital, came on soon after parturition. 
The proportion of cases from this cause, in relation to the whole 
number of admissions into the hospitals in Paris, has been estimated 
at about one to thirteen. Esquirol observes, that moral influences 
are generally more concerned in the production of puerperal mania, 
than the physiological changes that are effected in the system by 
child-bearing.* The despair and heart-rending grief which seduction, 
loss of reputation, and abandonment, inflict upon some ; the blighted 
hopes of success in life, and the consequent anticipations of poverty 
and want ; the faithless and unkind conduct of the cherished father ; 
these, and a number of other similar moral influences, frequently act, 

* Journal de Medecine, par Sedillot, torn. 61. 



154 MENTAL DERANGEMENT. 

in co-operation with the debility, exhaustion, and general physiological 
condition present in the puerperal state, in the development of mental 
derangement. Out of ninety-two cases of puerperal mania admitted 
into the Hospital Salpetriere during a period of four years, thirty-seven 
became affected with the disease between the first and fourteenth days 
after parturition; seventeen, between the fifteenth and sixteenth days; 
nineteen, between the sixty-first day and the eleventh month after 
confinement, and during lactation, and nineteen immediately after 
ceasing to suckle. (Casper.) 

Atmospheric influences also have a manifest agency in the causa- 
tion of insanity. It appears that summer and spring are decidedly 
most favourable to the occurrence of mental diseases. Casper asserts, 
that the admissions into Esquirol's private institution, during the six 
months from March to September, amounted to double the number 
that were admitted during the remainder of the year; and bythefol 
lowing statement of the admissions into the Hospital Salpetriere, for 
each month, during eight years, we perceive this fact sufficiently 
illustrated.* It appears, therefore, that high atmospheric heat is more 
favourable to the occurrence of mania than cold weather. 

Prostitution, and i,ts train of evils, syphilis, intoxication, and mer- 
cury, appear to be very common sources of insanity in populous 
cities — and according to Esquirol, particularly so in Paris. It is 
asserted, that a twentieth part of the insane females admitted into the 
Salpetriere were previously prostitutes. It is stated by Casper, that 
mental derangement from intoxication is found by the records of the 
Parisian hospitals to bear a proportion to the whole number of admis- 
sions, as 1 to 23 with females ; and 1 to 10 with males. In England. 
the proportion of lunatics from this cause appears to be greater. It 
has been estimated to amount to about one-fifth of all the cases that 
occur. Dr. Rush states, that at one time the number of maniacs in 
the Pennsylvania Hospital, in which the disease was excited by the 
excessive use of ardent spirits, amounted to one-third of the whole 
number ! 

Onanism, says Dr. Rush, is much more frequently the cause of in- 
sanity in young persons than is generally suspected.! According to 
the foregoing etiological table, it would appear that in Paris, insanity 
from this cause occurs in the proportion of one out of fifty-eight in 
women of the lower order of society ; and one out of fifty-one in males 
of the same class. In the higher classes it occurs in both sexes in the 
ratio of about one to twenty-three. 

Sudden suppression of the cutaneous transpiration often gives rise 
to mental derangement. Esquirol mentions the case of a man who 

* Admissions of lunatics in the Hospital Salpetriere from 1806 to 1814. Janu- 
ary, 162; February, 173; March, 187; April, 196; May, 243; June, 251; July, 
265 ; August, 239 ; September, 206 ; October, 197 ; November, 198 ; and December, 
191. 

t " La masturbation, ce fleau de l'espece humaine, est plus souvent, qu'on 
pense, cause de folie, surtout chez le riches." Esquirol, Diet, des Scien. Med., 
Art. Folie. 



MENTAL DERANGEMENT. 155 

was subject to copious sweating about the head. He became insane 
in consequence of having washed himself with cold water, with the 
view of restraining the profuse perspiration. "A young man waded 
across a rivulet while freely perspiring. He had a rigor on going 
to bed, and immediately afterwards became maniacal." 

Mental derangement, from repelled cutaneous affections, is by no 
means uncommon. Some very striking instances of this kind are 
related by Dr. Casper. He saw in one of the hospitals in Paris, a 
maniacal female of a plethoric habit, in whom the healing up of an 
old fistulous ulcer, on the left arm, excited the disease. A blister was 
laid upon the arm, which caused violent phlegmonous erysipelas over 
the whole extremity, and the re-opening of the ulcer. The patient was 
almost immediately relieved of her mental disease. In a short time, 
however, the ulcer cicatrized again, and the mania returned. He 
mentions another instance of mania, which came on immediately after 
healing an old ulcer on the leg. The ulcer was re-opened by local 
applications, and the mental affection disappeared. A young physi- 
cian became affected with erysipelas : the inflammation subsided, and 
was substituted by mania. After a long time he suffered a second 
attack of erysipelas, and the mania disappeared. 

Mania sometimes occurs in connection with consumption. There 
is, at this time, a young lady under my care, who has, for the last 
nine months, been in a state of complete insanity from this cause. 
About a year ago, phthisis pulmonalis developed itself in her system. 
Three months after unequivocal symptoms of the pulmonary affec- 
tion had come on, she became taciturn, morose, and finally maniacal. 
The consumptive symptoms continue, but she does not appear to be 
conscious of any disease of this kind. She coughs much, expecto- 
rates but little, has irregular hectic exacerbations, and night sweats. 
Haslam, indeed, denies that such a complication has ever occurred ; 
and maintains, that cases of this kind are to be regarded as co-exist- 
ing or concomitant diseases, without any mutual dependence between 
them.* The occurrence of insanity, as a consequence of pulmonary 
phthisis, is, however, well established. Dr. Casper saw an instance 
of this kind in the Hospital Salpetriere. When the cough and hectic 
symptoms were present, the patient was entirely free from derange- 
ment of mind ; but in the absence of the phthisical symptoms, the 
patient was furiously insane. 

Sudden reverse of fortune is one of the most frequent causes of 
melancholy. Out of four hundred and eighty-two melancholic patients 
admitted into the Hospital Salpetriere in the course of four years, 
forty-eight cases arose from this cause. It is generally believed that 
the moon has a decided influence upon maniacal subjects — an opinion 
which, I am inclined to believe, is founded on correct observation. 
Esquirol, however, entertains a different opinion. He observes, in- 
deed, that the insane are generally much more agitated and boister- 
ous about the full moon; but the same thing, he says, occurs about 
the break of day every morning. He thinks that light is the cause 

* Loc. cit., second edition, p. 591. 



156 



MENTAL DERANGEMENT. 



of this increased excitement of the maniacal symptoms at both periods. 
Light, he says, agitates all lunatics. 

Prognosis. — The degree of sanability of maniacal cases has of 
late years been an object of very particular inquiry ; and the various 
reports that have been published on this head, show that the number 
of instances in which a cure is effected is by no means inconsidera- 
ble. From the following tabular statement,* drawn up by Dr. Cas- 
per, from official reports, it appears as a general result, that in France 



* FRANCE. 


Period. 


11 

3 S 

25 ~ 


T3 

P 

O 


T3 
(B 

s 


c 
'3 


Discha'd 
partially 
relieved. 


o 

m 

P 


Decimal 
propor- 
tion of 
cured. 


Hosp. Salpetriere, 

Pinel, 

Esquirol, 

the same, 

Pinel, 
Hospital Bicetre — 

Chamseru, 
Hospital Charenton, 

Pinel, 

Fodere, 
Royer — Collard, 
Chamseru, 
Esquirol's priv. Ins., 
Dubuisson's, 


1801—1805 
1806 
1807 

1812—1814 

1807 

1789—1800 

1803 

1806 

i of 1807 

1801—1813 


1002 
333 
289 
891 

102 

97 
499 
355 
214 
335 
300 


473 
160 
136 
413 

33 

33 
161 
134 

91 
173 
177 


250 
33 

70 

36 


370 

140 

83 

142 




5 


0.47 1-5 
.48 

.47 1-18 
.46 1-5 

.32 1-3 

.34 

.32 1-4 
.36 2-3 
.42 1-2 
.51 7-11 
.59 


Sum for France, 




4417 


1984 










0.44 9-11 



ENGLAND. 




. 
















Bethlehem, according 




















to Haslam, 


1748- 


-1794 


8874 


2557 










.28 7-9 


Haslam, (dif. acc't,) 


1784- 


-1794 


1664 


574 










.34 1-2 


St. Luke's, Tuke, 


1751- 


-1819 


12173 


5091 


1013 


166 




5903 


.41 5-6 


Hospital at York, 




















Fodere, 


1777- 


-1807 


1739 


746 


192 


141 


410 


250 


.42 7-8 


Retreat at York, 




















Tuke, 


1796- 


-1811 


149 


49 


26 


47 


18 


9 


.32 4-5 


Hosp. at Manchester, 




















Fodere, 


1766- 


-1805 


1686 


667 


190 


85 


220 


324 


.39 1-2 


Hospital at Montrose, 




















Act of Pari, 


1805- 


-1815 


154 


34 


36 


54 


25 


5 


.22 1-13 


Hosp. at Nottingham, 




















Burrows, 


1812- 


-1819 


336 


179 


39 


48 




70 


.53 1-4 


Hospital at Exeter, 




















Burrows, 


1801- 


-1819 


626 


355 


53 


45 




173 


.56 5-7 


Hospital at Glasgow, 




















Burrows, 




1819 


183 


39 


10 


106 




28 


.21 1-3 


Hosp. at Manchester, 




















Burrows, 




1820 


350 


74 


31 


190 


2 


71 


.21 1-7 


Bethlehem, Act of Par- 




















liament, 


1800- 


-1815 


4810 


1839 










.39 1-4 


Sum for England, 




32744 


12204 






|o.37 2-5 



MENTAL DERANGEMENT. 



157 



0.44J- of maniacal patients are cured ; whilst in England the propor- 
tion is not so great, being only 0.37| of the whole number. 

In looking over the foregoing table we observe that the annual 
number of cures effected in the Hospital Charenton has been pretty 
uniform during a period of fourteen years. At Bethlem, on the 
contrary, we perceive that the difference in the proportion of cures 
effected, in the forty-six years from 1743 to 1794, and the fifteen 
years from 1S00 to 1815 is eleven per cent, in favour of the latter 
period— a strong evidence, says Dr. Casper, that in England the 
treatment of mental diseases has, within the last twenty-five-years, 
received great improvements. 

From the following summary of the cures effected by Esquirol in 
the Sulpetriere, we perceive that the chances of recovery decreased 
very rapidly after the second year ; and that after the fourth year, not 
more than one out of about 225 were cured. 



There were treated in 


the years 




















180-1 


1805 


1806 


1807 


1808 


1809 


1810 


1811 


1812 


1813 




Total number. 


209 


212 


206 


204 


188 


209 


190 


163 


208 


216 


total. 


Of which were 
























cured during the 
























1st year, 


64 


73 


78 


60 


64 


48 


48 


44 


75 


50 


604 


2d, 


47 


54 


49 


55 


57 


64 


•51 


30 


41 


49 


497 


3d, 


7 


4 


10 


11 


4 


9 


7 


8 


11 




71 


4th, 


4 


2 


3 


1 


2 


4 


1 


3 






20 


5th, 


3 


2 


1 




1 


1 


3 








11 


6th, 


2 


1 


1 


2 




3 










9 


7th, 






1 




1 












2 


8th, 


1 




















1 


9th, 


1 




















1 


10th, 
























11th, 




1 


















1 




129 


137 


143 


129 


129 


129 


110 


85 


127 


99 


1217 



Veitch, in his report in 1816, states, that of twenty-eight cases of 
recent insanity, admitted into his private institution, he cured eigh- 
teen, but of one hundred and twenty-five inveterate cases, he suc- 
ceeded only in five instances. In the Retreat at York, England, out 
of sixty-six patients cured of insanity, twenty-seven were affected 
during the first year, thirteen in the second, three in the third, one in 
the fourth, five in the fifth, three in the seventh, two in the ninth, one 
in the thirteenth, and one in the fifteenth. (Casper.) Pinel observes 
that after three years ineffectual treatment, the chance of cure in in- 
sanity will be about as one to thirty. 

Unfortunately, relapses are very common in mental diseases. In 
the Hospital Saltpetriere, relapses, according to the observations of 
Esquirol, have occurred in the proportion of about one in ten.* This 
■agrees pretty well with the facts stated by other writers on this 
point. Relapses are most apt to occur during the spring and summer 



* Casper, loc. cit., p. 405. 



158 MENTAL DERANGEMENT. 

months, and particularly at those seasons in which the disease had 
made its attack in the first instance. (Esquirol.) Dr. Hallaran ob- 
serves, that when a violent fit of mania subsides rapidly, it is par- 
ticularly apt to return. If the patient, soon after recovery from an 
attack of mania, becomes corpulent, there is not, in general, much 
probability of a relapse.* 

According to the observations of Esquirol and Georget, the mor- 
tality is greatest during the autumn and winter. Of seven hundred 
and ninety insane females that died during ten years, (1804 — 14,) in 
the Hospital Salpetriere, one hundred and seventy-five died in the 
months of March, April and May ; one hundred and seventy-four 
in June, July and August ; in September, October and November, 
the number of deaths amounted to two hundred and thirty-four, and 
in the three remaining winter months, to two hundred and seventy. 

With regard to age, it appears from the same observations, that 
the greatest number of deaths take place between the ages of forty 
and fifty in males, and between thirty and forty in females. 

Maniacal patients appear to be much less obnoxious to contagions 
and epidemic diseases than individuals who are of a sound mind. 
This fact has been particularly noticed by Rush, Dubuisson, Mead, 
Willis, Reil, and Cox. 

Mania sometimes terminates spontaneously, in consequence, ap- 
parently, of some critical evacuation. Dubuisson saw it cured by the 
supervention of dysentery, Esquirol by epistaxis ; Pinel and Hallaran 
through spontaneous salivation ; and instances are mentioned, of the 
subsidence of mental derangement soon after the occurrence of pro- 
fuse discharges of urine or tears, and, according to Bufl'on, of the 
semen. 

In general, the difficulty of curing monomania and melancholy, is 
greater than of the other forms of mental derangement. Haslam 
observes, that when melancholy alternates with raving madness, the 
chance of a cure is extremely small; and when monomania or melan- 
choly is converted into madness, almost every hope of a fortunate 
issue may be abandoned. 

Casper states, that Esquirol, in his lectures, observes, that when 
maniacs are able to recollect recent occurrences, with an oblivion of 
events long passed, the prognosis is much better than when they 
have a recollection of remote occurrences, without being able to 
remember what has recently transpired about them. Mania, con- 
nected with paralysis or epilepsy, may be regarded as absolutely 
hopeless. In general, acute and furious mania is much more under 
the control of remedial management than low, torpid and fatuous 
insanity. Mental derangement, from physical causes, generally yields 
more readily and permanently than when it arises from moral causes. 
A recovery of the general health of the system, without a correspond- 
ing melioration of the mental disease is said to be an unfavourable 
sign. Puerperal mania appears to be more frequently treated with 
success than any other form of mental derangement. 

* Haelam, loc. cit, p. 79. 



MENTAL DERANGEMENT. 159 

Post-mortem phenomena. — Notwithstanding the zeal and industry 
ith which post-mortem examinations have been pursued in relation 

mental diseases, we have as yet derived but very little information 
3in such researches concerning the nature and seat of insanity, 
squirol assured Dr. Casper that he had dissected the brains of more 
an twelve hundred subjects who had died of mania, and that he 
d not in a single instance discover any morbid appearances which 
e not found also in subjects who had never suffered any mental 
seases whatever. In almost every instance, however, he found the 
vo hemispheres of the cranium of unequal size — and this, he says, is 
le most constant phenomenon, and perhaps the most worthy of 
Mention.* 

Haslam, Reil, Esquirol, and others, state that in the majority of 
tses the brain is found preternaturally soft. Esquirol found the 
rain very soft in twenty-nine instances out of forty-four subjects ; 
l fifteen it was of a firm consistence. According to Georget, how- 
irer, softening of the brain is much more frequent than would ap- 
ear from Esquirol's statement. Ossification of the dura mater is, 
xording to the observations of Esquirol, no uncommon occurrence 
1 maniacal subjects. He observes, moreover, that he invariably 
mnd a very firm adhesion of the lining membrane of the lateral 
cntricles to the adjoining substance of the brain. In several in- 
ances, Georget found the cerebellum totally disorganized. (Casper.) 

Among the abnormal circumstances discovered in the thorax and 
bdomen, Esquirol mentions one in relation to the position of the 
ransverse colon, which is of a very remarkable character. This 
ortion of the intestinal tube, he says, is sometimes found sunk down 
) low as to pass into the pelvis, and often placed in a perpendicular 
istead of a transverse position. The phenomenon occurs most 
Dinmonly in persons who labour under melancholia. It must be 
bserved, however, that Mr. Lawrence asserts that instead of having 
Hind this position of the colon in those who had laboured under 
isanity, he has seen it only in such as had never been affected by 
ny mental diseases whatever. We perceive, from these contradictory 
bservations, how little reliance is, in general, to be placed on the 
weeping inferences which are so frequently drawn from post-mortem 
ppearances, in relation to the proximate cause and essential location 
f diseases. 

The diseases of the mind may be divided into four classes : viz., 
tania, monomania, dementia, and idiotism. 

I. Mania. 

General mental derangement is characterized by a rapid succes- 
on of incoherent ideas, and violent excitement of the passions, ex- 
ressed by great agitation, loud vociferation, singing, menaces and 
iry. 

Mania is generally preceded by a marked change in the habits, 

* Diet, des Sciences Med., Art Idiotism. 



160 MENTAL DERANGEMENT. 

tastes, attachments, and passions of the patient. He is usually ani- 
mated, his sensibilities are keen, his ideas rapid, his temper irritable, 
jealous and wayward. He is eccentric in his conversation and con- 
duct ; often betrays an unusually vicious disposition; he sleeps but 
little; is harassed by frightful dreams; forms various and extrava- 
gant plans for the increase of his fortune, or the good of the public; 
enters into ruinous speculations, or squanders away his means in 
childish or extravagant amusements, or in the purchase of unneces- 
sary or useless articles of furniture, clothing, &c. Costivencss, a 
craving appetite, vertigo, cephalalgia, a sense of throbbing and ten- 
sion in the head ; and a dull and wild expression of the eyes, are 
among the common premonitory symptoms of mania. When the 
disease is once completely developed, the expression of the counte- 
nance is wild, and often ferocious; the eyes are prominent, spark- 
ling, and in constant motion; the patient sings, whistles, vociferates, 
halloos, walks to and fro with rapidity, "or stands still with his 
hands and eyes often raised towards the heavens ;" he does not sleep 
for many nights, sometimes not for weeks; he often manifests great 
muscular power; the skin is dry, cool, and occasionally covered with 
profuse perspiration; the sensorial organs are extremely excitable; 
the appetite is sometimes craving, at others wholly absent; the 
bowels constipated, and the urine small in quantity and high-co- 
loured. The pulse is variable — sometimes full and strong, at others 
small, irregular and tense, or slow and intermitting, and occasionally 
morbidly natural. (Rush.) Perhaps the most constant and remark- 
able among the physical phenomena of mania, are continued watch- 
fulness, and a very peculiar disagreeable odour, which exhales from 
the patient's bosly and excretions, and impregnates his cloths and 
bedding. (Esquirol.)* Some patients are tortured with a constant 
severe internal heat ; and the majority experience pain in the head, 
or in some part or organ in the abdomen or thorax. 

In the violent grades of mania, the mind forms erroneous percep- 
tions of the impressions of external objects on the senses, or the senses 
convey erroneous impressions to the mind. In this case the patient 
does not recognize the objects and persons around him; mistakes 
"friends for strangers, and common visitors for his relations," loses 
the consciousness of his individuality, and "is ignorant of the place 
he occupies, of his rank and condition in society, and of the lapse of 
time." The imagination is sometimes so powerfully excited, that its 
representations prevail over those of the senses. The patient hears 
voices, holds conversations with persons who he imasines are present, 
and in some cases these voices pursue and harass him wherever he 
goes, by day and by night, in public and in private. (Esquirol.) 
Sometimes the empire of volition seems to be entirely suspended, 
and the patient is no longer master of his own determinations. An 
irresistible impulse leads him to injure himself, or to inflict injury on 
others, to tear the clothes from his body, run out naked into the streets, 

* This peculiar smell issuing from the bodies of maniacal patients, is also par- 
ticularly noticed by Wagoner, Simes, and Reil.— Reil, Fieberlchre, b. iv, p. 348. 



MENTAL DERANGEMENT. 161 

leap out of the windows, and to commit various other acts of fury. 
The sense of modesty and delicacy is generally wholly obliterated, 
and "people of the finest previous feelings will deliver themselves 
up to the most indecent or culpable actions, without the conscious- 
ness of impropriety." 

Mania may be continued, intermittent, or remittent. A single 
paroxysm may continue from a few days to several months, before 
it terminates in a remission, intermission, or in death. Some patients 
experience paroxysms of maniacal excitement at regular intervals of 
a day, a week, or months — the intervals being passed in a state of 
quiet and inoffensive insanity.* Mania may also assume a chronic 
form, with little or no distinct exacerbations. This constitutes what 
Dr. Rush has called manalgia. It is usually characterized by " taci- 
turnity, downcast looks, a total neglect of dress and person, long nails 
and beard, disheveled or matted hair, indifference to all surrounding 
objects, and insensibility to heat and cold." 



II. Monomania. 

Monomania consists in a state of partial insanity — the patient being 
insane upon some one subject only, with a full and regular use of his 
intellectual faculties " upon all or nearly all other subjects." This 
class of mental diseases comprehends many varieties, as nostalgia, 
fanaticism, hypochondriasis, melancholia, misanthropy, satyriasis, &c. 

This is by far the most common form of mental derangement, and 
is always entirely free from delirium or paroxysmal raving. In that 
variety which is usually denominated hypochondriasis, the hallucina- 
tion relates to the patient's own body, or to the circumstances which 
he conceives have an especial sinister influence upon his own system, 
fortune, or happiness. The suggestions of his morbid imagination 
are taken from realities. He believes himself afflicted with certain 
incurable and fatal diseases, "particularly with consumption, cancer, 
stone, and above all, with impotency and the venereal disease." He 
fancies that some poison has been maliciously introduced into his 
system ;t or that he has a living animal, or some other very injurious 
substance in his stomach or bowels. Some patients believe themselves 

* Those remissions, says Esquirol, sometimes offer very remarkable anomalies. 
A patient will, for instance, remain in a slate of profound melancholy for three 
months, the three following months will be passed in a state of high maniacal ex- 
citement, and to this three months of complete fatuity will succeed. 

f Some years ago there was a foreigner — a barber, in Lancaster — who continued 
to occupy himself regularly and cheerfully with his customers, and to converse 
rationally upon all subjects except his own fortune, and the universal conspira- 
tion among his neighbours to poison him. He cooked his own victuals, and 
regularly every morning went about a mile to the river Conestoga to supply him- 
self with water, which he asserted could contain no poison, since the fish continued 
to live in it. 

VOL. II. — 12 



162 MENTAL DERANGEMENT. 

transformed into inferior animals, as dogs, cats, wolves,* oxen,t cocks,t 
&c. Others imagine themselves converted into trees, plants, pots, 
clocks, candles, glass, butter, straw, wax,&c. The following lines, by 
Pope, give a sufficient enumeration of these singular hallucinations. 
Unnumbered throngs on every side are seen, 
Of bodies changed by various forms of spleen. 
Here living tea-pots stand, one arm held out, 
One bent ; the handle this and that the spout; 
A pipkin there,. like Homer's tripod walks, 
Here sighs a jar, and there a goose-pie talks. 
Men prove with child, as powerful fancy works, 
And maids, turned bottles, cry aloud for corks. 

Tissot mentions an instance, in which the 'patient believed himself 
to be a lump of butter, and would not suffer any fire near him, lest 
he should melt. An eminent painter imagined himself made of wax, 
and avoided all contact with hard substances. (Tulpius.) Zacutus 
Lusitanus mentions a person who believed that his posteriors were 
composed of glass, and would on no account sit on any thing but the 
softest pillows. Some hypochondriacs have thought themselves dead; 
others imagined that their souls formerly resided in some inferior 
animal, or in some fellow creature ; in short, almost every imaginable 
hallucination of this kind has been known to occur in this variety of 
mental disease. 

In many instances of monomania, the hallucination is not of dis- 
tressing or sombre character. Some patients, though perfectly sane 
upon every other subject, have an unalterable belief that they are 
destined to make some great discovery, as the perpetual motion, the 
philosopher's stone, the squaring of the circle, &c. Others imagine 
themselves the legal heirs of crowns, princely fortunes, and hereditary 
honours. Professor Titel, of Jena, continued to perform his profes- 
sional duties for some time, although labouring under the fixed hallu- 
cination of believing himself to be Emperor of Rome.§ I knew a 
person who, for more than twenty years, was firmly persuaded that he 
was the President of the United States; and yet this individual would 
converse and think rationally upon all the ordinary concerns of life. 
Some believe themselves invested with a special commission from 
heaven to perform certain pious acts, or to commit some deed, often 
cruel and horrid, under the persuasion that it is the command of Provi- 

* Qui lycanthropia detinentur, noctu, domo egressi, lupos in cunctis imitator, et 
donee dies illucessat. circa defunctorum monumenta plerumque vagantur.— P. 
JF.gineta. De re Med., lib. iii, cap. 16. 

t This was the case with the daughter of the king of the Argives, whom Virgil 
mentions. — Protidcs implerunt falsis mugibus agros. Eclog. vi. The madness of 
Nebuchadnezzar appears also to have been of this kind. 

X Alter gallos cantare audiens, ut hi alarum ante canrum, sic ille brachiorum 
plausu latera quatiens, animantium sonum imitatus est. — Galen, de locis affectit, 
lib. iii, c. vi, as quoted in Red's Fieberlehre. 

$ Reil, Fieberlehre, b. iv, p. 39. 



MENTAL DERANGEMENT. 163 

dence, and necessary for the general welfare of the world.* Others 
fancy they converse with spirits, angels, and messengers from heaven. 
Tasso, in the latter years of his life, obstinately maintained that a 
spirit regularly visited, and held conversations with him.t Was not 
the celebrated Swedenborg a monomaniac ?{ Some monomaniacs 
have believed themselves to be the Messiah. Dr. Rush informs us 
that he has seen two instances of this kind. •< We see this form of 
mania," says Dr. Rush, "in the enthusiastic votaries of all pursuits 
and arts of men. The alchymists, the searchers after perpetual motion, 
the metaphysicians, the politicians, the knight-errants, and the travel- 
ers, have all in their turns furnished cases of this form of derange- 
ment.'^ 

III. Dementia. 

This variety of mental disorder " consists not in false perception, 
like the worst grades of madness, but of an association of unrelated 
perceptions, or ideas, from the inability of the mind to perform the 
operations of judgment and" reason. The judgments are generally 
excited by sensible objects, but ideas, collected together without order, 
frequently constitute a paroxysm of the disease. It is always accom- 
panied with great volubility of speech, or with bodily gestures, per- 
formed with a kind of convulsive rapidity. We rarely meet with 
this disease in hospitals; but there is scarcely a city, a village, or a 
country place, that does not furnish one or more instances of it. 
Persons who are afflicted with it are good-tempered and quarrel- 
some, malicious and kind, generous and miserly, all in the course of 
the same day."|| 

Dementia is, therefore, directly opposed, in its phenomena and cha- 
racter, to monomania; for in this latter variety of insanity, the mind 
is fixed upon some particular subject, and upon which alone it hal- 
lucinates; whilst in dementia, there is no leading idea, and, "the 
mind," as Dr. Rush expresses it, " may be considered as floating in 
a balloon, and at the mercy of every object and thought that acts 
upon it." 

* Pinel mentions a case of a monk who imagined that the Holy Virgin had 
commanded him to murder a person whom he considered an unbeliever, 
t Poole'a Life of Tasso, p. 48. 
% Of this kind of hallucination was that of the man mentioned by Horace: — 

Fuit haud ignobilis Agris 

Qui se credebat miros audire tragcedos, 
In vacuo, laetus sessor, plausorque theatro. 
Cetera qui vitac servaret munia recto 
More, &c. 
$ Boileau says : — 

Tous les hommes sont fous; et malgre tons leur soins, 
Ne different entre eux, que du plus au du moins. — Sat. iv, p. 27. 
II Rush on the Diseases of the Mind, chap. ix. 



164 MENTAL DERANGEMENT. 



IV. Idiot ism. 



This variety consists in a defective development, or impairment, of 
all the intellectual faculties, amounting sometimes to a total absence 
of mind ; and in some instances, even to a destitution of the instinct 
which leads to the gratification of the animal appetites. Idiotism is 
frequently congenital. It may, however, be produced by various 
causes, as apoplexy, epilepsy, chorea, blows on the head, onanism, &c. 
It is the most hopeless form of mental disease ; and, when congenital, 
or produced by the spasmodic affections just mentioned, it may be 
regarded as absolutely irremediable. 

Treatment of Mental Diseases. 

In France, England, and the United States, there is, in general, but 
little medicine employed in the treatment of mental diseases. In the 
year 1819, the expenses incurred for medicines at the Glasgow Lu- 
natic Asylum was but eighteen pounds sterling, whilst the sum 
expended for food and beer amounted to £1225. At the Exeter 
Hospital £1162 was expended for food and only £33 for medicines 
and instruments during the year 1S19; and in the institution at 
Nottingham, the necessaries of life cost £920, whilst the expense for 
medicine was only seven pounds, during the same period. 

Fifty years ago, the amount of expenses for medicines for the same 
number of patients, during an equal period, would have been much 
greater, although the proportion of cures effected was then consider- 
ably smaller than at present. Even at the present day, much more 
medicine is employed, according to Dr. Casper, for the cure of insa- 
nity, in the German hospitals, than in those of England and France, 
although the success of the former appears to be considerably less 
tljan that obtained in the latter.* The truth is, medicines, properly 
so called, are by no means the most useful agents in the treatment 
of a majority of mental diseases. Much more is in general to be 
effected by appropriate moral influences — by kind and humane 
treatment, and comfortable seclusion. The physician who looks for 
particular success in the management of lunatics, must enter into 
their feelings — take an interest in their real or imagined pleasures 
and pains, soothe and admonish them in a tone of kindness and af- 
fection, and appear among them, not as a stern ruler, but as a sym- 
pathizing friend and protector. It is by a moral treatment of this 
kind, more than by the materia medica, that the most good may in 
general be done in the management of patients labouring under 
mental diseases. The cruel and coercive measures that were formerly 
so generally adopted in the treatment of insane persons, are as inju- 
rious as they are repugnant to the best feelings of the heart. Humanity 
and reason combine against the employment of such remedial mea- 

* In Berlin, the proportion of cures effected has been estimated at about 0.28 ■ 
at Vienna about 0.27— whereas in France it averages about 44. Casper loc* 
cit., p. 413. 



MENTAL DERANGEMENT. 165 

gures; and the triumph of reason and good feeling over cruelty and 
error, is nowhere more delightfully illustrated than in the improve- 
ment that has of late years been effected in this respect. Instead of 
subduing the miserable maniac with implements of terror and torture, 
or keeping him in trembling subjection by threatening looks and 
menaces, or endeavouring to put reason right by drugs, chains, cells, 
and hand-cuffs, physicians now know that a kindlier mode of man- 
agement will often call back the unsettled and wandering intellect, 
when a contrary course would only fix it the more firmly in its wild 
and distracted mood. 

One of the first measures in the treatment of mania, should be to 
remove the patient from his friends and home, and to place him in 
some quiet and secluded situation. Dr. Rush strongly insists upon the 
importance of separation and proper seclusion ; and the most eminent 
of the English, German, and French writers, advise the adoption of 
this measure. " Confined to a regular life and discipline," says Es- 
quirol, "the patient is naturally led to reflect on this change "in his 
situation ; while the necessity of living among and submitting to the 
control of strangers is to him a powerful stimulus to regain his lost 
freedom and reason." When thus confined, the medical attendant 
must in the first place endeavour to obtain the confidence and good 
will of the patient. Kindness, consolation, affability, and in some 
cases a moderate yielding to the hallucination, will in general soon 
acquire the patient's confidence. Having gained this point, he must 
"soothe the irritable, repress the insolent, cheer the desponding, calm 
tlie excited, check the forward, encourage the timid, resist the impor- 
tunate and petulant, but carefully attend to all reasonable requests." 
(Knight.) 

Let it be observed, however, that in recommending separation and 
confinement, it is not intended to object to regular exercise in the 
open air, and the enjoyment of the society of suitable persons during 
the patient's intervals of comparative calmness. Whenever the wea- 
ther is favourable, and the patient's condition will admit of it, free air 
and ample exercise should be allowed. The mutual association of 
patients similarly affected, and particularly during convalescence, has 
also a favourable tendency. "Nothing," says Georget, "contributes 
more to the recovery than the mutual association of convalescents;" 
and for this purpose, it is particularly important that the institutions 
in which insane patients are placed, should have extensive gardens, 
well furnished with trees and flower-beds, and instruments of bodily 
amusements, such as swings, &c. 

Idleness in monomaniac patients should be discouraged. Various 
amusing exercises— "as playing at quoits, the chase, shooting, and 
even chess, checkers, cards, and push-pin, should be preferred to idle- 
ness." (Rush.) Indeed, in cases of a moderate grade of maniacal 
excitement, traveling will sometimes do much good. Esquirol 
slates, that he has always found the disease conspicuously moderated, 
after a lontr journey, particularly if it has been attended with difficul- 
ties and privations, and performed through a strange country. It is 
on this account, perhaps, that foreigners are more apt to be cured in 



166 MENTAL DERANGEMENT. 

England, than natives, ( Wills ;) and that strangers sent to Paris are 
more readily restored to reason than the inhabitants of that city. 

I have stated above, that in order to obtain the patient's confi- 
dence, it may be proper, occasionally, to give way in some degree to 
his hallucinations. This, however, must he done with caution. In 
general, it is improper to encourage, in any degree, the particular 
error, or false ideas under which the patient labours, and this is more 
especially to be observed with monomaniac patients. On the other 
hand, however, peremptory and absolute contradiction, is perhaps 
still more unfavourable than indulgence ; for it seldom fails to excite 
the anger and contempt of the unfortunate sufferer against the person 
who thus vehemently opposes the current of his hallucinated notions. 
" In the furious state, insane patients," says Dr. Rush, "should never 
be contradicted, however absurd their opinions and assertions may 
be, nor should we deny their requests by our answers, when it is im- 
proper to grant them. In the second grade of the disease, we should 
divert them from the subjects upon which they are deranged, and 
introduce, as it were accidentally, subjects of another and of an agree- 
able nature. When they are upon the recovery, we may oppose their 
opinions and incoherent tales, by reasoning, contradiction, and even 
ridicule." 

Where the insanity turns upon some prominent idea, or passion, 
much benefit may sometimes be obtained by dexterously exciting 
some counteracting emotion, or sentiment. Esquirol states, that a 
melancholic man, who was in a state of great despondency, had his 
intellectual energies restored, by having been told that he had a law- 
suit on hand. An insane soldier was informed that the campaign 
was about to open. He immediately requested permission to join the 
army ; it was granted, and he arrived at his regiment perfectly sane. 
" The excitement of new turns of thought," says Georget,"the rous- 
ing of inert faculties, form a third principle of moral treatment. For 
instance, endeavour to convince a king that he is without power, 
with the hope of reflecting that he may have been in error. Take 
the patient to the situation whence the subject of his hallucination 
proceeds ; as, for instance, fancied voices, enemies, &c, and assure him 
of their non-reality. Awaken the passions, by reproaching them 
with indifference to parents, &c. ; relate to them their past conduct, 
by telling them of their designs, as suicide, destruction of children, 
hatred to husbands, &c. ; and by this management cures may some- 
times be effected. In some instances it will be proper to substitute 
a real for an imaginary grievance." If a melancholic is harassed by 
ennui, withdraw him from his usual sources of amusement, so as to 
inflict on him real privations. The real ennui which he will then 
suffer, will often prove a powerful means of diverting his mind from 
its hallucinations. If a patient, says Esquirol, imagines himself 
abandoned by his friends, we may sometimes promote his recovery by 
depriving him of every testimony of their affection, and thus awaken- 
ing him to a sense of his real loss. Dr. Rush relates some remarkable 
instances in which sudden terror, excited by actual danger, had the 
effect of curing insanity. 



MENTAL DERANGEMENT. 167 

The attempt to laugh or ridicule hypochondriacs out of their 
erroneous conceptions, is in general as injurious as it is cruel. Upon 
this point Dr. Reid makes the following sensible and humane observa- 
tions. " No one was ever laughed or scolded out of hypochondriasis. 
It is scarcely likely that we should elevate a person's spirit by insult- 
ing his understanding. The malady of the nerves is, in general, of 
too obstinate a nature to yield to a sarcasm or a sneer. It would 
scarcely be more preposterous to think of dissipating a dropsy of 
the chest, than a distemper of the mind, by the force of ridicule or 
rebuke. The hypochondriac may feel, indeed, the edge of satire as 
keenly as he would that of a sword ; but although its point should 
penetrate his bosom, it would not be likely to let out from it any 
portion of that noxious matter by which it is so painfully oppressed. 
By indirect and imperceptible means, the attention may, in many 
instances, be gently and insensibly enticed, but seldom can we safely 
attempt to force it from any habitual topic of painful contemplation."* 
During the exacerbations or periods of excitement, it sometimes 
becomes necessary to employ coercive measures. The only means 
employed for this purpose in the hospitals of this country, and I 
believe also in those of Paris, is the strait jacket and Rush's tran- 
quilizer. Haslam condemns the former mode of restraining patients, 
in strong terms. It is certainly an offensive and oppressive mode of 
coercion in a state of furious mania. Haslam employs instead of it, 
a belt from eight to ten inches wide. This is passed round the lower 
part of the body, above the arch of the pubis, and fastened on the 
back by strong buckles. On each side, leather bags are fastened. 
Into these the hands of the patient are thrust, and secured there by 
proper bandages. By this contrivance the respiration is not impeded 
as is always the case, to a greater or less degree, with the strait 
waistcoat ; nor is the perspiration suffered to become offensive and 
injurious by being absorbed and retained in the waistcoat. Patients, 
too, may walk about with this belt without much inconvenience, 
and they are said to endure it with much more patience than the 
jacket. In Dubuisson's private institution, an arm-chair, resembling 
Dr. Rush's tranquilizer, is used as a mode of coercion. It consists 
of an arm-chair with a high back, and foot-board. The arms, legs, 
feet and body are fastened to this chair by strong and broad straps 
furnished with buckles. 

A simple and very excellent means for moderating the violence of 
a paroxysm of a mania, is the total exclusion of tight from the 
patient. This is daily practised in the Salpetriere. When a maniac 
begins to rave violently, a piece of thick cloth is quickly thrown 
over his head, and fastened over the eyes. This, it is said, generally 
immediately moderates the patient's fury, and he may then easily 
be conducted into his apartment and properly secured. Esquirol 
particularly lays great stress on the soothing influence of darkness on 
maniacs ; and Dr. Rush enjoins it as a measure of much importance 
during the first stage of the disease. Confinement, darkness, soli- 

* Essays on Hypochondriacal and other Nervous Affections. By John Reid, M. D. 



168 MENTAL DERANGEMENT. 

tude, low diet and cold affusions, will rarely foil to subdue the most 
turbulent and furious maniacs. 

Medicinal treatment.— Blood-letting was formerly much more 
commonly resorted to in maniacal diseases than is now done. Dr. 
Rush was a strenuous advocate for the employment of this evacua- 
tion in general menial derangement; and the old established trade- 
merit de V Hotel Dieu, says Pinel, consisted almost entirely of re- 
peated blood-lettings. In the Parisian and English institutions, we 
are told that venesection is now but rarely employed in mental dis- 
eases. There can be no doubt, however, that the abstraction of blood 
will often contribute considerably to the reduction and removal of 
acute mania : and we may safely and advantageously resort to this 
measure in all instances in which the pulse is full and active, or tense, 
corded, and quick, in connection with "great wakefulness, redness 
of the eyes, a ferocious countenance, and a noisy and refractory be- 
haviour." When the disease assumes the grade of phrenitis, with 
raving delirium, a hard and bounding pulse, throbbing of the caro- 
tids, flushed face, red eyes, prompt and free venesection cannot with 
propriety be dispensed with. Georget* says, that in cases that occur 
about the pubertal period, accompanied, as they usually are, with 
general plethora, repeated small bleedings are particularly useful; 
and the same observation applies to cases that occur at the turn of 
life in females. When mental derangement is attended with sup- 
pression of an habitual sanguineous evacuation, cupping or leeching 
near the parts from which such discharges occurred, will sometimes 
contribute considerably to the removal of the mental malady.t In 
monomania, or generally in all those varieties of mental alienation 
that are unattended with paroxysms of high cerebral excitement, 
bleeding can do no good, and may prove permanently injurious. 

Purgatives are often very useful auxiliaries in the remedial 
management of lunatics. Where there is reason to believe that the 
bowels are in a loaded condition, or irritated by vitiated secretions, 
that is, where the tongue is furred, with pain on pressure in the re- 
gion of the liver, a hard abdomen, and constipation, active purgation 
is particularly proper. Dr. Prichard observes, that in cases of this 
kind, (enteric mania,) the rectified oil of turpentine, in union with 
castor oil, is decidedly the most valuable purgative. Esquirol pre- 
fers mercurial purgatives, with the view of exciting the biliary secre- 
tion ; and in instances where tension and tenderness exist in the right 
hypochondrium,therecan be little doubt of their superiority. "There 
are cases," says Dr. Rush, "in which purges should be given daily, 
so as to excite an artificial diarrhoea," and calomel and jalap should 
be preferred for this purpose. When there is reason to suspect the 
existence of verminous irritation, anthelmintics should be given, in 
conjunction or alternation with active purgatives. Infusion of the root 
of spigelia, followed by a full dose of turpentine and castor oil, gene- 
rally answers this purpose better than any other articles of this kind. 

* De la Folie, p. 293. 

t D. Ratier, Formulaire Pratique des Hopitaux Civiles de Paris, &c, &c. 



MENTAL DERANGEMENT. 169 

Emetics may occasionally be employed with manifest advantage, 
in the milder forms of mental derangement — more especially in melan- 
cholia, and in recent cases of hypochondriasis. They are improper, 
however, where there is much cerebral irritation, or in cases attended 
with much febrile excitement. Esquirol has found emetics useful in 
puerperal mania. 

Mercury is much recommended by some writers, whilst others 
condemn its use in maniacal affections. With Dr. Rush, it was a 
favourite remedy in mania. « Too much," he observes, "cannot be 
said in favour of salivation in general madness;" and lie strongly 
recommends it also in partial insanity. As an alterative, it may 
be used, occasionally, with very considerable advantage in chronic 
mania, particularly where the disease is attended with prominent 
functional disorder of the biliary organs. Dr. Knight states that he 
has found the blue pill a valuable medicine in cases of long standing, 
and that he never knew it to be productive of any injurious effects ; 
but he apprehends, that in recent cases of mania, the constitutional 
influence of mercury must be prejudicial in any form.* 

Narcotics and antispasmodics were formerly much employed in the 
various forms of mental derangement, and although by no means 
generally applicable, they may in some cases be used with advan- 
tage, after the general indications have been adequately attended to. 
Opium, when given in small doses, says Dr. Rush, may be useful, 
but it should never be given in large doses, with a view of procuring 
sleep in general mania. Regimen, exercise, purgatives, and the use 
of the warm bath, will commonly do more towards procuring sleep 
than any other remedies that can be employed. Indeed, opium never 
fails to increase the wakefulness, and when given in strong doses, 
before the general and cerebral excitements have subsided, it rarely 
fails to aggravate the disease. In chronic mania from masturbation, 
camphor has been recommended ; but almost all recent writers agree, 
that it very rarely produces any good effects, but on the contrary often 
manifest injury. In puerperal mania, however, Dr. Grooch asserts 
that camphor, given in union with the extract of hyoscyamus, (ten 
grains of each,) is the most useful anodyne we possess! Dr. Knight 
also has found this combination very useful as a soporific in mania 
unattended with sanguineous congestion in the brain, or a general 
phlogistic habit.f 

In maniacal affections succeeding the sudden suppression of the 
catamenia from cold, or any powerful mental emotion, advantage may 
be expected, says Dr. Priehard, from stimulating emmenagogues, in 
conjunction with efficient abstractions of blood, and warm semi- 
cupia. He considers the tincture of melampodium and the oil of 
turpentine, as decidedly the best emmenagogues in cases of this kind. 

* Observations on the Causes, Symptoms, and Treatment of Derangement of 
the Mind, &c. By Paul Knight, M. D. 

t Observations on Puerperal Insanity. Transact, of Lond. College of Phys., 
1820, vol. vi. 

X Loc. cit. 



170 MENTAL DERANGEMENT. 

Georget also recommends the use of emmenagogues, in conjunction 
with mustard pediluvia, hip-baths, and leeches to the pudenda, in 
cases attended with suppressed menstruation and cephalalgia. 

The warm bath is a cardinal remedy in the treatment of insanity 
in the Parisian hospitals. In the Salpe.trilre, the women use the 
warm bath two or three times a week, unless an apoplectic tendency, 
or some other circumstance contra-indicating its use, be present. 
They remain in the bath from a half to two hours. (Casper.) Patiente 
of a thin, nervous and irritable habit of body, says Esquirol, may be 
kept in the warm bath a very considerable time with advantage. 
When the vessels of the head are strongly congested, and much 
cerebral irritation is present, clothes saturated with cold water should 
be applied to the head, while the patient is in the bath. The heat of 
the water should be about 99° or 100° of Fahrenheit. 

The cold bath, also, has been much employed in maniacal affec- 
tions. In young, robust, and sanguineous patients, particularly when 
the skin is dry and preternaturally warm, considerable benefit will 
occasionally accrue from cold affusions. More advantage, however, 
may, in general, be obtained from the application of cold water or ice 
to the head, in young and excited maniacs with much sanguineous 
determination to the brain. In the early stages of mania, where there 
is much headache, redness of the face and eyes, and turgidity of the 
vessels of the head, cold affusions " from a cock, funnel, or pitcher," 
upon the top of the head, after leeching or cupping, with stimulating 
pediluvia and laxative enemata, often produce the most excellent 
effects.* " The signal for removing the cold applications," says Dr. 
Rush, "should, be, when they produce chilliness, and sobbing or 
weeping in the patient." Dubuisson, in conformity with the recom- 
mendation of Hill and Cox, has applied ether to the head with much 
advantage.! 

Counter-irritating applications may occasionally be employed 
with benefit in insanity. Esquirol was formerly much in the habit 
of applying moxas to the back part of the head, in cases attended 
with much torpor, but he has for some years past, in a great measure, 
discontinued this practice. " They augment," he says, " the erethism, 
torment the patient, increase his irritability, and convince the insane 
that he is a victim to our cruelty.f Georget, however, speaks strongly 
in favour of setons, moxa and blisters to the neck, in monomania, 
and other varieties of mental derangement accompanied with stupor, 
insensibility and cerebral inactivity. These, he says, in conjunction 
with the repeated exhibition of vomits, rouse the energies of the 
nervous system, in the most desperate cases of alihiees stupides. 
Dr. Rush, also, speaks decidedly in favour of the use of blisters. 
" They have," he says, « been considered as remedies of doubtful 
efficacy ; but it is only because they have not been employed in the 
manner, or at the precise time that was necessary to obtain benefit 
from them. In the first stage of tonic or violent madness, the disease 

* Esquirol, loc. cit. 

t Des Vesanies on Maladies Mentales, p. 225. % Loc. citat. 



DELIRIUM TREMENS. 171 

is entrenched, as it were, in the brain. It must be loosened, or weak- 
ened, by depleting remedies, before it can be dislodged, or translated 
to another part of the body. When this is effected, blisters easily 
attract it to the lower limbs, and thus often convey it at once out of 
the body." 

The circular swing has been much used in the institution for 
lunatics at Glasgow, and "in some cases, with wonderful good 
effects." Dr. Knight also asserts that this agent possesses " immense 
power" in subduing general and cerebral excitement. "A patient 
subjected to its action, is speedily affected with giddiness and sick- 
ness, and the peristaltic motion of the whole alimentary canal seems 
to be excited, and in some instances to such a degree that the patient 
vomits, and passes feces in rapid succession and great abundance, 
along with his urine. Apprehensions have been expressed, lest the 
use of the circular swing should induce apoplexy ; having attentively 
examined the sources of these fears, I conclude them to be ground- 
less; nor have lever seen the slightest reason to apprehend such 
result; nor do I believe it can occur, if the patient be not in a 
furious state when put into the swing." The best time, says Dr. 
Knight, for using the swing, " is a little before retiring to rest at night, 
as the unloading of the alimentary canal, the lowering, and the re- 
laxation of the skin, very generally predispose to sound and refresh- 
ing sleep.* 

Music sometimes has a most soothing influence over the distracted 
and raving minds of maniacal patienis. Dr. Rush observes, that 
"lively tunes are as offensive as comic representations in this dis- 
ease." Tissot relates an instance of insanity which was permanently 
removed by music ;t and we read that Saul's melancholy was dis- 
sipated by the harp of David. — Tange lyram digit is, animi dolor 
omnis abibit,dulcisonnm reficit tristia corda rnelos. 



Sect. II. — Delirium Tremens. — Mania a Potu. 

This very remarkable variety of mental disease, is characterized 
by general inquietude, tremor, continued watchfulness, cool skin, 
perspiration, delirious loquacity, and sensorial illusions. 

It occurs only in habitual drunkards, and in such as are addicted 
to the inordinate use of opium, and, perhaps, other narcotic stimu- 
lants. So long as the customary quantity of the stimulus is taken, 
the disease seldom, if ever, supervenes ; but if from necessity, sick- 
ness, or a temporary disgust, the ordinary stimulating potations are 
suddenly left off, or greatly diminished, the activity of the brain 
becomes morbidly increased, and mental disorder, in many instances, 
speedily ensues. " It is important to bear in mind," says Dr. Coates, 
"that this disease is the result, not of the application, but of the 
sudden intermission of the use of these articles."! 

* Loc. cit., p. 63. t Reil's Fieberlehre. 

X See an able and highly interesting memoir on this disease, by Dr. Coates, of 
this city, published in the North American Med. and Surg. Journ., vol. vii, p. 34. 



172 DELIRIUM TREMENS. 

The disease usually commences with lassitude, general indisposi- 
tion, a feeling of distress in the epigastrium, anorexia, nausea and 
vomiting, giddiness, a sense of confusion in the head, want of sleep, 
an anxious expression of the countenance, and tremor of the hands. 
After a day or two, the countenance exhibits an expression of alarm 
and suspicion, the eyes are cast about with quick and scrutinizing 
glances, or often fixed, apparently upon some object that attracts the 
attention for a moment, and then quickly withdrawn; the tremor of 
the hands increases; the patient becomes irritable, and sometimes 
irascible; he is extremely restless, walks continually to and fro, and 
is wholly unable to obtain a moment's sleep, lie now begins to 
manifest mental disorder, becomes loquacious, says he feels well, and 
is tormented with a more or less continued succession of various 
alarming, disgusting, and ludicrous apparitions. He fancies that he 
sees dogs, snakes, cats, mice, and other animals in his room, and dis- 
gusting vermin crawling over the bed, and on his clothes, or that 
various persons have entered his room, for the purpose of robbing, 
killing, or annoying him. To avoid these and other horrid illu- 
sions, lie often calls out loudly for assistance; runs to the door to 
make his escape, or to the window to leap out ; is greatly agitated, 
vociferates, threatens, and sometimes raves violently. Sometimes he 
fancies that he hears loud and strange noises around him, over head, 
in an adjoining apartment, or loud and frequent knocking at the door. 
His mind and body are in a continued state of action; he calculates, 
projects, walks hurriedly about the room, picks up money, runs up 
to the window, and calls out to some imaginary person in the street, 
starts with terror and agitation from the presence of frightful and 
disgusting apparitions, insists that he is well, and confined with some 
sinister intentions against him, and requests to be suffered to go out 
in pursuit of his usual occupations. ]f the patient is flatly contra- 
dicted, he usually becomes much exasperated, and insists with vehe- 
mence on the correctness of his notions ; but, when he is soothingly 
dealt with, he will now and then answer certain questions mildly 
and even distinctly, and by judicious management, may, in general, 
be restrained without any violent coercive measures. When the dis- 
ease rises to a high grade, the patient becomes violently and often 
furiously delirious, talks incessantly, is restrained with difficulty, and 
is unable to recognize his friends and acquaintances. 

Patients affected with this disease do not appear to be susceptible 
of much bodily pain. " They never seem to experience any suffer- 
ings from fractures, though they may be at the time subjecting these 
to the most constant friction and concussion ; and when the delirium 
supervenes upon a pleurisy, or other inflammatory affection, accom- 
panied with pain, the principal disease seems to disappear, even to 
the eye of the experienced practitioner, to be reproduced at a later 
period, when the brain and nerves regain their ordinary tranquillity." 
(Coates.) 

The pulse in this disease varies considerably in different cases. In 
some instances it is hard, full, and frequent,'but much more com- 
monly soft, full and quick, without strength or tension. The skin 



DELIRIUM TREMENS. 173 

generally retains its natural temperature and moisture ; the tongue 
is humid, and covered with a white fur; the bowels are torpid, and 
there is usually an entire loathing of food throughout the whole 
course of the disease, but the thirst for cold drinks is almost always 
considerable. 

The duration and degree of violence of delirium tremens vary 
much in different cases. Sometimes slight tremor of the hands, with 
occasional transient manifestations of delirium, sensorial illusions and 
watchfulness, continue for a day or two, and then pass off. At others, 
the wakefulness, tremor of the hands, and general restlessness and 
agitation, continue for five or six days, with delirium and annoying 
apparitions at night, whilst during the day but little mental halluci- 
nation is noticed. In some cases, the symptoms described above, 
continue, with but slight remissions, day and night for one or two 
weeks and upwards, and in highly aggravated instances, the disease 
assumes the character of wild and ungovernable mania. Dr. Arm- 
strong observes that when convalescence is not restored within the 
first month, there will be a risk of long-continued, if not permanent 
alienation of mind. 

Mild cases of this disease, when left to themselves, have been 
known to terminate spontaneously (Stoughton,) on the supervention 
of diarrhoea or vomiting. The occurrence of profuse discharges of 
this kind, however, often brings on a low and typhoid condition of 
the system ; and this is especially apt to be the case in persons who 
have been long and exceedingly intemperate, and in whom the dis- 
ease is accompanied by some local inflammatory affection or general 
fever. In lull and robust habits, the disease not unfrequently termi- 
nates in fatal convulsions or apoplexy. 

Pathology. — It appears to be generally admitted that this disease 
has its primary and essential location in the sensorium commune, and 
that it is wholly independent of inflammation or vascular turgescence 
in this organ. It would seem to consist in a purely dynamic disorder 
— a morbid activity of the brain, from the sudden abstraction of an 
habitual stimulus by which its excitability had been long repressed 
or blunted. Dr. Coates considers it as consisting in " a heightened 
activity of the sensorium," from the generation, as it would seem, of 
an inordinate degree of vital activity in the brain ;* and similar views 
of the nature of this affection have been expressed by Dr. James 
Johnson,, Dr. Ayre, and many other eminent British physicians.t Dr. 
Joseph Klapp, of this city, has published a series of cases, with obser- 
vations, tending to show that the proximate or essential irritation of 
this disease is seated in the stomach, and it must be confessed that 
the arguments adduced in support of this opinion possess consider- 
able plausibility.;): It is asserted, in support of this opinion, that dis- 
section almost uniformly discloses traces of previous inflammation in 
the stomach ; that, in nearly all instances, nausea, vomiting and a 

* Loc. cit., p. 225. 

t Med. Chir. Rev., Feb., 1828, p. 484. 

$ Eclectic Repertory, vol. vii, p. 259. 



174 DELIRIUM TREMENS. 

foul tongue occur; and that the operation of an emetic, in many 
cases, brings off from the stomach a viscid, light-brown, or black- 
coloured fluid, of the consistence of boiled tar; and, finally, that the 
disease yields more frequently and speedily under the employment of 
emetics, than under any other mode of remedial management that 
has hitherto been recommended. 

In reply to these arguments it may be observed, that post-mortem 
signs of inflammation cannot be received as a valid proof that the 
inflammation was primary and causative, in relation to the peculiar 
trai/i of phenomena which characterize the disease ; for nothing 
appears to be more satisfactorily established than that mucous in- 
flammation of the alimentary canal very often supervenes during the 
latter period of all violent diseases ; and that the ordinary signs of 
inflammation— increased vascularity and sanguineous engorgement 
— are frequently produced in the last moments of life, or in articulo 
mortis. If the disease depended on mucous inflammation of the 
stomach, can it be conceived that emetics should in any instance 
operate beneficially ? Would any prudent physician prescribe an 
emetic in a case attended with unequivocal gastritis? Dr. Klapp, 
indeed, does not appear to consider the morbid condition of the sto- 
mach as a state of inflammation ; although Dr. Stoughton, who 
advocates the gastric pathology of this affection, lays particular stress 
on the post-mortem signs of phlogosis in the stomach, as an evidence 
of the correctness of this pathology. Dr. Klapp seems to consider 
the gastric affection as rather the reverse of inflammation — as a state 
of torpor, insensibility, and chronic irritation, or morbid excitement 
of the stomach. The argument drawn in favour of this opinion from 
the occasional good effects of emetics in this malady, affords it but 
little support. The post hoc, ergo propter hoc, is always a fallacious 
mode of reasoning. We may admit, to the full extent, the beneficial 
influence of emesis, and yet consistently deny our assent to the doc- 
trine which alleges that the stomach is the primary seat of the dis- 
ease. With regard to the foul tongue, vomiting, &c, mentioned in 
confirmation of this view of the nature of the disease, it may be 
observed, that the majority of writers do not bear testimony to the 
frequent occurrence of these phenomena. Dr. Coates found them 
" generally absent in the cases that came under his own inspection." 
Dr. Sutton mentions them only as symptoms accompanying the dis- 
ease, where it occurred in connection with typhus fever, scarlatina, 
or some other acute affection; and Dr. Brown, of New York, has 
noticed a foul tongue only in two out of eight cases, Within the 
last six years, I have seen about ten cases of this disease, and al- 
though I have paid particular attention to all the phenomena that 
might throw light on its pathology, I do not remember of having 
noticed a foul tongue in more than three instances, one of which was 
complicated with pneumonia, and another with dysenteric symptoms. 

Prognosis.— Delirium tremens is not, in general, a very dangerous 
affection, when it occurs in a simple and uncomplicated form, and in 
systems not yet greatly broken down and depraved by a long course 
of excessive intemperance. When it supervenes during the course 



DELIRIUM TREMENS. 175 

of violent forms of fever, and more especially during the exislence of 
acute visceral inflammation, it almost invariably terminates fatally. 
The disease is also attended with peculiar danger when it occurs in 
confirmed drunkards, who have previously laboured under chronic 
hepatitis, or some similar organic affection. Subjects of this kind, 
generally, rapidly sink under the disease. (Armstrong.) When the 
delirium becomes constant, the pulse rapid and very small, the ex- 
tremities cold and covered with perspiration, the pupils small and 
contracted, with subsultus tendinum, and an agitated motion of the 
muscles of the face, death may be regarded as inevitable. It is also 
a particularly unfavourable sign, when coma, with sonorous respira- 
tion or convulsions, ensues. The occurrence of tranquil sleep, even 
of short duration, announces a favourable tendency in the disease ; 
and no symptoms can be regarded as indicative of declension of the 
malady, so long as the patient is unable to obtain some sleep. 

Treatment. — If delirium tremens depends — as lam well persuaded 
it does — on a morbid activity of the sensorium, independent of in- 
flammation or sanguineous congestion, the prominent indication is 
obviously to subdue this inordinate cerebral activity; and it remains 
only to inquire, by what remedies or course of treatment this object 
is best accomplished. 

If we attend to the circumstance that this peculiar condition of the 
brain is almost invariably the consequence, not of the application, 
but of the sudden abstraction of the customary stimulus, we are 
led, a priori, to infer, that the best mode of removing it is to supply 
a stimulus, which may be capable at once of blunting and exhaust- 
ing the morbid excitability of the sensorium. For this purpose 
opium is decidedly the most valuable remedy we possess. Dr. Coates 
observes, and correctly too, that sleep must be produced coute qui 
coute— that the patient must sleep or die. Dr. Coates, however, goes 
too far, I think, when he expresses his conviction, that every case of 
simple delirium tremens may be cured by the " opiate treatment." 
Satisfied as I am that opium is the remedium magnum — the "sheet 
anchor" of our hopes, in this affection — there nevertheless exists no 
doubt in my mind, that important advantages may also be derived, 
in some instances, from other remedies, auxiliary to this potent nar- 
cotic. When the bowels are constipated, and there is reason to 
presume that they are in a loaded state, a purgative should be admi- 
nistered before recourse is had to the opium. This, like all other 
affections, may come on while the intestinal canal is charged with 
vitiated secretions and other irritating substances; and when it is 
considered that intestinal irritation from sources of this kind, has a 
powerful tendency to originate and support morbid excitement in the 
brain, the propriety of administering one or two active purgatives 
preparatory and auxiliary to the employment of opium in this disease 
would appear to be very obvious. It has appeared to me, indeed, 
that without this precaution, the free use of opium has a tendency, in 
some instances, to cause dangerous determinations to the head, and to 
bring on coma instead of healthy sleep. About four years ago, I 
was called to a gentleman, a few miles from the city, labouring under 



176 DELIRIUM TREMENS. 

the ordinary symptoms of this disease. I found him silting on his 
bed, busily engaged in driving away eels and snakes, which, he said, 
were annoying him; and he requested me to turn out of the room 
several negro children, who had placed themselves, he thought, on 
the tops of the bed-posts. This was the second day of his illness; 
his pulse was moderately full and compressible, and his tongue 
covered with a white fur. I at once directed two;grains of opium to 
be given to him every hour, and to be continued until sleep should 
ensue. In the evening I visited him again. I found him lying on 
his back, apparently perfectly unconscious, his hands and arms, and 
muscles of the face, in continual motion, uninterruptedly muttering 
indistinct words; the pupils contracted, and the whole frame in a 
state of tremulous agitation. The skin was moderately warm and 
moist, and the pulse frequent, small, and more firm than on the pre- 
ceding day. With much difficulty I got him to swallow about an 
ounce of castor oil, with three drachms of oil of turpentine, and 
directed a laxative enema to be administered in two hours after- 
wards. Early next morning I saw him again, and found him much 
relieved. The purgative had acted four or live limes, and brought 
away large and very offensive stools. He immediately recognized 
me when I entered the room; his pulse was frequent and feeble, and 
he was still much harassed by various disgusting and alarming 
apparitions. I now directed him a grain of opium every hour; 
after the eighth dose was taken, he fell into a tranquil sleep, which 
lasted several hours. He recovered under the use of this narcotic, 
without any other remedy. I cannot, indeed, assert with certainly 
that the comatose stale mentioned above was the result of the influ- 
ence of the opium; but lam led to ascribe it to this cause, from 
having, in another instance, witnessed similar phenomena, after the 
use of large doses of this narcotic. Dr. Coates says: '• I have never 
seen, read of, or heard of an instance in which opium was productive 
of harm." I must, indeed, be greatly mistaken in the diagnosis, if 
I have not seen one unequivocal instance of this kind. In a case 
which I regarded as pure and uncomplicated delirium tremens, four 
grain doses of opium were given every two hours. In twelve hours 
the patient was comatose, became convulsed, and soon expired. 1 
mention these facts, not to deter from the use of tins valuable, and, 1 
may say, indispensable remedy in this affection, but as a caution to 
the practitioner to watch with assiduity its administration; "because 
we know not whether poisonous effects will be produced by an arith- 
metical or a geometrical increase — whether five grains, or thirty grains 
in addition, are sufficient to endanger the patient's life."* 

The quantity of opium which it is usually necessary to administer, 
before the desired soporific effect is produced, is often truly enormous. 
In some instances, from twenty to thirty grains, in divided but fre- 
quent doses, are required, before the full advantage can be obtained, 
which it is capable of affording. My usual practice has been to exhibit 
two grains every hour (after free purgation) until sleep is induced. 

* Coates, loc. cit., p. 214. 



DELIRIUM TREMENS. 177 

With regard to the employment of blood-letting in this affection, 
the opinion of the profession seems to be pretty well settled as to its 
general impropriety and inefficiency. Dr. Sntton informs ns, that 
where blood-letting " has been principally relied on, he has observed 
a fatal termination of the disease in almost every case."* Dr. Arm- 
strong, who is not inclined to undervalue this measure, asserts, that 
he is "fully persuaded that there are not many instances where the 
lancet is requisite ;" yet " in constitutions that have not been shaken 
by reiterated drunkenness, he has known early and moderate vene^ 
section of much use." The experience of Dr. Brown, of New-York, 
coincides with the observations of Dr. Armstrong on this point. Dr. 
Stewart " had seen the disease on a large scale. Almost all those 
patients who were treated on the antiphlogistic plan died, while 
those who were treated by opium and stimulants recovered "t The 
experience of Dr. Gregory, Dr. Shiel, Mr. Lambert, Mr. Mackelan, 
Mr. Chinnock, and Dr. Ayre, is decidedly against the use of blood 
letting, and in favour of the stimulating and narcotic treatment, in 
uncomplicated cases of the disease.^ My own experience is en- 
tirely opposed to the employment of the lancet, under the ordinary 
circumstances of this malady. In very plethoric and robust subjects, 
it will, nevertheless, be proper to draw some blood, with the view of 
lessening the liability to dangerous sanguineous congestion in the 
brain ; and thus enabling us to proceed with more confidence in the 
employment of opium. 

Cupping about the head may, under certain circumstances, prove 
very useful. Where the sanguineous determination to the brain is 
considerable, and the raving becomes constant and violent, cups may 
be applied to the temples, forehead, and neck, with much advantage. 
Dr. Coates informs us, that in the Pennsylvania. Hospital, Dr. Parrish 
has resorted to cupping in delirium tremens, with great benefit. In 
an instance I attended about six months ago, where there was much 
vascular turgescence of the head, and a state of delirium approaching 
the raving of phrenitis, immediate and very decided benefit was 
derived from cuppitig. Blisters also will sometimes act beneficially 
when applied to the legs, or to the back of the neck, in cases attended 
with violent cerebral excitement. In one case, in which the disease 
seemed to verge into phrenitis, a large blister, laid between the 
shoulders, mitigated the symptoms very considerably. 

Dr. Coates, referring to the practice of Dr. Parrish in the Pennsyl- 
vania Hospital, observes, that blisters appear of more service than 
cupping, "as they did not equally weaken the patient." 

Emetics, as has already been intimated, deserve more attention 
as curative means in delirium tremens, than any other remedies that 
have been employed, with the exception of opium. In my own 
practice, I have had unequivocal testimony of the occasional use- 
fulness of emetics in this malady. In several instances, however, 

* Tracts on Delirium Tremens, &c., p. 66. 
t Med. Chir. Rev., February, 1828, p. 484. 
% Ibid., p. 485. 
VOL. II. — 13 



178 DELIRIUM TREMENS. 

they failed, in my hands, of doing any good; and in two cases, 
within the last six years, they were unequivocally injurious. To 
one patient, who had been long a confirmed drunkard, I administered, 
in divided doses, fifteen grains of tartar emetic. It produced neither 
purging nor vomiting; but its sedative operation was immediate and 
powerful. In about an hour after taking the medicine, the pulse 
became small and extremely feeble— the extremities ice-cold, and a 
profuse, cold, clammy sweat broke out over the whole body. The 
patient sunk rapidly, and expired about four hours after the anti- 
mony was taken. In the other instance, the emetic brought on the 
most profuse and exhausting diarrhoea, and soon prostrated the 
patient below the point of reaction. Nevertheless, in moderate and 
uncomplicated instances of the disease, and in patients who have 
still considerable constitutional vigour left, we may with safety, and 
often with decisive advantage, resort to one or two emetics. As an 
auxiliary or preparatory measure to the employment of opium, I am 
satisfied that the exhibition of an emetic is often peculiarly bene- 
ficial. I have known a few cases cured by emetics, with little or no 
other remedial applications ; but experience has convinced me, that 
they are much more worthy of attention as auxiliaries to opium, 
than as a principal curative means. Dr. Brown expresses the same 
opinion. "Although it has not been our practice," he says, " to depend 
exclusively upon emetics in the treatment of delirium tremens, we 
can bear testimony to the utility, in some cases, of premising an 
emetic to the use of opium. And, no doubt, this is often an im- 
portant step in the treatment of this disease."* 

It is often extremely difficult in this disease to excite vomiting, 
without administering very large doses. Dr. Klapp gave one of his 
patients twenty grains of tartar emetic before vomiting was excited; 
and Dr. Brown mentions an instance in which thirty grains of this 
article were given before the desired effect was produced. I have, 
in general, preferred giving the tartar emetic in combination with 
ipecacuanha, in the proportion of two grains of the former with 
fifteen of the latter, repeated every ten or fifteen minutes, until 
vomiting ensues. 

Cold and tepid affusions, also, have been recommended in this 
affection. Dr. Armstrong speaks favourably of the effects of dash- 
ing two or three gallons of tepid water, strongly impregnated with 
salt, over the whole body, and then immediately drying and rubbing 
the surface with warm flannel ; and, having put the patient to bed, 
administering forty or fifty drops of tinct. opii, in a little warm wine. 
He informs us, also, that in several cases he used cold affusions with 
decided benefit; but he never resorted to this measure except in 
patients possessing much apparent vigour of constitution, and he 
always administered stimulants — such as warm wine— immediately 
afterwards. 

Besides opium, various other stimulating remedies have been em- 

* Observations on Delirium Tremens, &c, by Dr. Stephen Brown, in the Med. 
Recorder, vol. v ; p. 207. 



NEURALGIA. 179 

ployed in delirium tremens. Dr. Coates considers camphor and 
assafetida " as powerful agents in restoring the mind to its equili- 
brium." I have used camphor and opium in combination ; but I 
cannot say that more benefit was derived from this mixture than is 
visually obtained from the latter article, when given by itself. In 
several instances, I gave the camphorated tincture of opium, dur- 
ing the declension of the disease, with the happiest effect. Two 
drachms of it may be given every three or four hours during conva- 
lescence. The carbonate of ammonia, also, may be given with more 
or less benefit in slight cases, or during the subsidence of the disease. 
I prescribed this article lately in a case of incipient delirium tremens, 
with marked advantage. With regard to the employment of ardent 
spirits, I can say nothing from my own experience, as I have never 
allowed my patients to take any thing of this kind, except warm wine, 
and, in a few instances, a little weak brandy toddy. The sentiment 
of the profession appears now very generally and strongly opposed 
to the employment of spirituous liquors in the treatment of this affec- 
tion. There is, indeed, something very revolting in the idea of 
exhibiting copious draughts of the very agent whose destructive 
influence has caused the wreck of body and mind, which we are 
called on to remedy. There can be no doubt that opium will, in 
general, do all that can be effected by remedies of this kind ; and 
where it may be thought advisable to bring in the aid of a more 
diffusible stimulus, camphor, ammonia, assafetida, and Hoffman's 
anodyne, may be resorted to with propriety. 

During the course of the disease and particularly during conva- 
lescence, the diet should be light, unirritating, and fluid. Animal 
broths will, in general, answer better than any thing else.* 



CHAPTER III. 

LOCAL CHRONIC NERVOUS AFFECTIONS, 

Sect. I. — Neuralgia — Tic Douloureux. 

The first account of this affection was given in 1756, under the 
name of tic douloureux, by M. Andre, of Versailles. Ten years 

* [I caught an excellent idea some years ago from the inaugural thesis of a 
candidate for the degree of M. D. He was a pupil of Dr. Hunt, a distinguished 
practitioner of Northampton, Mass. He gave his preceptor the credit of having 
cured several cases of mania-a-potu by a novel plan of treatment, which consisted 
chiefly in removing all appearances of restraint or confinement, and allowing the 
patient to wander about the house and out of doors until he wore down the mor- 
bid excitability of his brain and nervous system. 1 have often since acted upon 
that idea, and tranquilized patients into a sound sleep after all other plans of 
treatment have failed. — Mc] 



180 NEURALGIA. 

after this short and rather indistinct description was given, Dr. Fo- 
thergill published a paper, in which this painful affection is clearly 
and very circumstantially described, under the name of faciei mor- 
bus nervorum excrucians, and since that period, various interesting 
and elaborate essays, and a multitude of cases, illustrating the cha- 
racter and treatment of this disease, have been given to the public. 
The term neuralgia, which was, I believe, first given to the disease 
by Dr. Meglin, of Strasburgh, is now generally, and certainly with 
much propriety, preferred to the name tic douloureux. 

Neuralgia is usually divided into different species, according to the 
seat of this affection ; but the fact, now well ascertained, that its attacks 
are confined to no particular nerve or system of nerves, that it may- 
occur in almost every sentient structure of the body, in the cerebro- 
spinal, the pneumogastric and phrenic nerves, and even in the gang- 
lionic nerves arising from the solar plexus, renders the propriety of 
such divisions as specific distinctions very doubtful ; and the more so, 
as they do not appear to involve any essential peculiarities, either in a 
pathological or therapeutic point of view. Unquestionably, however, 
certain nerves are much more liable to become the seat of this affec- 
tion than others ; and this is especially the case with the three grand 
divisions of the fifth, and the facial portion of the seventh pair of cere- 
bral nerves. 

Symptoms. — The pain in neuralgic affections is very peculiar. It 
is extremely acute, and darts like lightning from its more fixed point 
along the course of the nerves. It comes on in sudden paroxysms, 
with longer or shorter intervals of more or less complete freedom 
from suffering. In general, much pain is experienced throughout 
the whole paroxysm, with frequent transitory shocks of darting pain, 
so extremely agonizing as often to cause a temporary loss of reason 
and consciousness. Occasionally, the paroxysm consists of a succes- 
sion of transient fits of pain, coming on with the suddenness of an 
electric shock, with short intervals of comparative ease. During the 
paroxysms, the surrounding parts are extremely sensitive or tender 
to the touch ; and it is a remarkable circumstance, that the slightest 
touch, in many instances, causes much more suffering than firm pres- 
sure ; the former, generally, instantaneously bringing on a shock of the 
piercing nervous pain. In general, the pain is attended with consi- 
derable turgescence of the blood-vessels in the immediate neighbour- 
hood of the affected part ; and this vascular engorgement, says Dr. 
Macculloch, sometimes " amounts to a species of inflammation, re- 
sembling that of rheumatism." Much general soreness in the part is 
usually left after the subsidence of the acute neuralgic pains; but in 
some cases only a little tenderness remains, which gradually subsides, 
and leaves the patient in his ordinary state of health. In very violent 
attacks of the disease, we generally find the neighbouring muscles 
affected with spasms, and occasionally spasmodic twitches occur in 
the muscles of parts distant from the place where the pain is located. 
When the disease occurs in the nerves of the face, the saliva is often 
secreted very copiously, and, in nearly all instances of this kind, there 
is a profuse flow of tears from the eyes during the paroxysms. In 



NEURALGIA. 181 

individuals of a nervous temperament, it is not uncommon to observe 
sympathetic affections of other and distant nerves, with which those 
affected have no other connection than that which exists through the 
medium of the sensorium commune. 

In some cases, the paroxysms are strictly periodical in their recur- 
rence, with regular intermissions of comparative health, the type being 
almost always quotidian. This periodicity of the paroxysms occurs 
only in what may be termed the acute or recent form of the disease ; 
and is particularly pointed out by Dr. Macculloch as an evidence 
of the affinity or rather identity of this affection with intermittent 
fever. Sometimes the disease assumes a chronic character, continu- 
ing in irregularly recurring paroxysms for months or even years, with 
scarcely any intervals of entire freedom from uneasiness, ill-health, 
or suffering; and this is especially apt to be the case, when the disease 
occurs in consequence of some mechanical injury of a nerve. 

This affection occurs much more frequently in the face than in any 
other part of the body. When the portio dura is affected, the pain 
usually commences on the side of the face, near the ear, and darts 
along the ramifications of the nerve, to the angle of the jaw, the alae 
of the nose, the angle of the mouth, external canthus of the eye, and 
along the temple to the forehead. Sometimes the pain radiates from 
a point on the cheek just below the orbit of the eye, and passes to the 
side of the nose, the upper lip, teeth, gums, and temple, in which 
case the disease is seated in the second branch of the fifth pair of 
nerves. When the principal pain is experienced in the internal can- 
thus of the eye, forehead, eyelids, and in the ball of the eye, we may 
presume that the first branch of the fifth pair is affected ; and in cases 
where the tongue and lower jaw are the seat of much pain, the neu- 
ralgic irritation extends to the third branch of the trigeminus. Some- 
times the pain occurs in the scalp ; and I have seen an instance of 
extreme violence, in which the pains were most severely felt behind 
the ear, and along the scalp of the occiput and the posterior portion 
of the temporal bone. 

The optic nerve, also, has been known to be affected with neuralgia. 
Dr. Macculloch mentions a case in which the pain in the eye was de- 
scribed by the patient as if a red-hot needle had been passed through 
its centre.* The decidedly neuralgic character of this pain was evident 
from its having occurred the moment after an attack of neuralgia in 
the upper jaw had ceased t 

Neuralgia in the nerves of the extremities is by no means uncom- 
mon. Dr. Macculloch mentions a severe case that occurred in the 
radial nerve which runs along the metacarpal bone of the fore-finger. 
The pain was confined to a space " which a pea could have covered," 
and continued during a period of four months. Mr. Abernethy has 
related a striking instance of neuralgia, which affected the superficial 

* An Essay on the Remittent and Intermittent Diseases, including, generically, 
Marsh Fever and Neuralgia, &c. By John Macculloch, M. D. 

t [This pain must have been felt by a fdament of the 1st branch of the 5th pair. 
According to sound physiology, the other is a nerve of special sense, and can never 
experience common sensation. — Mc] 



182 NEURALGIA. 

nerves under and adjoining the inner edge of the nail of the ring-finger 
of the hand ;* and Dr. Pearson has given an account of a remarkable 
case affecting the extremity of the left thumb. t 

The occurrence of this affection in the nerves of the feet and legs 
has been frequently noticed. I have lately seen an instance of this 
kind which has already lasted upwards of six months. Dr. Good, 
who makes a distinct species of such cases, under the term neural- 
gia pedis, describes an instance of this kind, which continued for 
several years. The paroxysms were transient, of uncertain recur- 
rence, and so severe as nearly to cause fainting, darting up the calf 
of the leg towards the knee, and downwards into the toes. Dr. 
Macculloch relates instances of neuralgia of the knee. In two 
extremely violent cases, the pain was situated immediately over the 
margin of the head of the tibia, and the affected part was not more 
than an inch in area. In another case, imitating the double tertian 
type, " there was on one day pain in both knees, and on the alter- 
nating day a pain in one arm;" and in this way the disease con- 
tinued a long time. Neuralgic pains in this joint, says this writer, 
have been mistaken for scrofulous affections, "and in some cases that 
had lasted five years, as the pain was very severe, the surprise had 
long been, that no swelling could be discovered by the touch." This 
affection is what Mr. Brodie has described under the name of hyste- 
rical white swelling; and he appears to think, " that nine out of ten 
of those unfortunate young women who have been doctored of late 
years for spinal diseases, have really laboured under nothing but 
hysterical pains of the back."J 

The tibia has been frequently the seat of extremely violent neu- 
ralgia ; and it has also occurred in the thigh, particularly in the ante- 
rior crural nerve, shooting down with great severity, from near the 
groin to the foot or toes. 

The occurrence of neuralgia in the breasts of females has of late 
years been noticed by several writers. The third species of Dr. 
Good's subdivision of this affection, (neuralgias mammas,) is founded 
upon this location of the disease. He describes an interesting case 
of this kind. " The breast," he says, " was full-formed and soft, 
without the slightest degree of inflammation or hardness. When the 
paroxysm of pain was not present, it would bear pressure without 
inconvenience, but during the pain the whole breast was acutely 
sensible. The paroxysms returned at first five or six times a day, 
and were transient, but as the disease became more fixed it became 
also more severe and extensive, for the agonizing fits at length 
recurred as often as once an hour, and sometimes more frequently." 
Dr. Addison says, that neuralgic pain under the mammas, or under 
the margin of the ribs of the left side, is far from being uncommon 
in females. This pain, he observes, is « very circumscribed, and will 
often last for weeks or even months, with but little intermission. It 

* Surgical Works, vol. ii . p. 18. 

t Med. Chir. Transact., vol. viii, part i. 

t Med. Chir. Rev., Nov., 1828, p. 58. 



NEURALGIA. 183 

is often associated with palpitation of the heart, or what is much 
more unusual, with unnatural pulsation of the organ, i.e., the patient 
is conscious of the heart's action, or she feels as if its impulse were 
communicated to a part so sensitive as to excite distinct sensation."* 

The internal organs, as was observed above, are no less liable to 
neuralgic affections than the external parts. Of the neuralgia of the 
heart, I shall speak more particularly under the head of angina 
pectoris ; for it will scarcely admit of a doubt that in some instances 
at least, this appalling affection is strictly of a neuralgic character. 
The occurrence of neuralgia in the abdominal viscera appears also to 
be much more common than is generally suspected. Dr. Macculloch 
has met with a well-marked instance of neuralgia in the rectum. 
There is an affection of this kind which occasionally occurs at the 
extremity of the rectum or coccygis, immediately after parturition, 
causing indescribable suffering to the patient, and which scarcely 
any dose of laudanum is adequate to allay. Dr. Dewees, in his 
Midwifery, mentions a remarkable instance of this kind, and I have 
not long since met with one equally striking. The pain continued 
for two hours before it began to decline. 

The painful affection usually termed gastralgia, is probably 
purely neuralgic in its nature. In this variety of the disease, the 
pain is paroxysmal, sometimes quotidian, and usually radiates from 
the epigastrium to the thoracic parietes, the back, and to the shoul- 
ders. The tongue is white, the saliva abundant, without thirst, and 
epigastric tenderness on pressure. Immediately after eating, the 
pain generally abates for some time, but in the course of one, two, or 
even three hours afterwards, it is renewed with a feeling of weight 
and distress in the epigastrium, as if there was a foreign body in the 
stomach. Nausea, borborygmi, flatulent colic, and eructations of air 
are usually experienced some hours after eating. There is generally 
much constipation, and the urine is usually pale, and small in quan- 
tity. In violent and protracted cases, difficulty of breathing, palpi- 
tation of the heart, wandering pains, and a peculiar sensation of 
coldness in the arms, loins, and lower extremities are wont to occur. 
In the morning the patient commonly gets up refreshed, and feels 
quite well until breakfast renews the gastric pains, t Dr. Prus has 
recently reported a very interesting case of neuralgia of the stomach, 
which was brought on by violent mental emotion. The patient, a 
female, was affected with excruciating pains in the epigastrium, 
which came on daily in paroxysms, between the hours of three and 
half past seven P. M. Fourteen years after the commencement of 
her sufferings, the patient consulted Dr. P. The epigastric pain was 
removed in five days by full doses of quinine, given during the inter- 
mission, and the patient appeared to be entirely cured. On the 
twenty-second day afterwards, however, intense pain occurred in the 

* Observations on the Disorders of Females ; connected with Uterine Irritation. 
By Thomas Addison, M. D., &c, Lond., 1830. 

t For a detailed account of the diagnosis between gastralgia, and chronic gas- 
tritis, see the section on gastritis in the first volume of this work. 



1S4 NEURALGIA. 

course of the infra-orbital nerve ; soon afterwards it seated itself in 
the cubital nerve of one arm, where it remained but a very short 
time. It then returned to the face. A blister was now applied be- 
neath each trochanter. After this the sciatic nerves of the right side 
became violently painful. Blisters were applied along the course of 
the nerve, and in a few days more the pain suddenly shifted to the 
left sciatic nerve, and soon afterwards disappeared altogether.* The 
kidneys, also, may become the seat of this affection. Dr. Maccul- 
loch states that he has met with an unequivocal instance of this kind. 
There is an exceedingly painful affection which occurs in the right 
iliac region, usually confined to a very circumscribed space, and 
which has been generally regarded as the result of calculous irrita- 
tion in the ureters, but which appears, very manifestly, I think, to 
be purely neuralgic. I have met with five or six cases of this kind, 
several of which continued to recur daily for two or three months. 
Its mere nervous character seems to be demonstrated by the strict 
periodicity which it observes in its recurrence ; although in most 
instances there is retraction of the testicle on the affected side, as in 
calculous irritation, without, however, any difficulty or diminution 
of the discharge of urine. 

The uterus also is liable to become the seat of extremely painful 
affections of this kind, in females of a nervous or hysterical tempera- 
ment. Dr. Jolly, in the second part of his Memoir on Visceral Neu- 
ralgia, has reported some severe and well-marked cases of neuralgia 
of the uterus. In one instance, the affection assumed a strictly quoti- 
dian intermittent type. After some manifestations of catamenial 
irregularity, the patient became affected with violent pains in the right 
iliac region, shooting into the pelvis, and extending to the left iliac 
region. These pains were acute, lancinating, recurring every three 
or four minutes, and soon acquired such a degree of violence, as to 
cause some delirium, and even convulsions. The attacks came on 
about noon, and continued until the evening. On the following 
morning, the patient appeared in good health, and without any pain, 
but about mid-day the paroxysms returned. After trying a variety 
of means ineffectually, eight grains of quinine were given during 
the remission, and the paroxysms were arrested. Mr. Jolly relates 
another highly interesting case of neuralgic affection of the trisplanch- 
nic nerves, which assumed the tertian type. The patient, a lady, 
aged thirty, soon after accouchement, experienced most violent attacks, 
which resembled gastritis, nephritis, hepatitis, hysteritis, &c, according 
to the organ principally invaded. Active depletory measures were 
employed, until the patient was reduced to a very low state, without 
any permanent favourable impression being made on the disease. 
At last, recourse was had to quinine and opium, during the intermis- 
sions, and under the use of these remedies the disease yielded speedi- 
ly.! Mr. Shaw has related a case, where the neuralgic affection 
was seated in the ulnar nerve, from the elbow to the little finger. 

* Med. Chir. Rev. ; March, 1829, p. 553. 

f Bib. Med., Juin, 1828. See, also, Med. Chir. Rev., Sept., 1828. 



NEURALGIA. 1S5 

After some local rubefacient applications, and the internal use of blue 
pill, and the volatile tincture of valerian, the pain abated in the arm; 
but the patient (a female) was attacked . with severe pains in the 
uterus. It would seem, too, that neuralgia sometimes invades the 
bladder. In a conversation which I lately had with Dr. Parrish, he 
mentioned an instance that occurred in his practice, which he called 
tic douloureux of the bladder. 

' M. Martinet has related some singular instances of neuralgia,* 
which assumed the general appearances of cerebral disease. One case 
commenced suddenly with incomplete paralysis of the right lower 
extremity, attended with pain running along the sciatic nerve; next 
a dull pain, with formication, occurred in the region of the loins — in 
a few days afterwards pains radiating along the temples, forehead, 
and upper eyelid of the right side came on — then distortion of the 
mouth to the left side, embarrassment of speech, with pain in the 
facial nerves, darting pains along the scalp, deep-seated cephalalgia in 
the right side of the head, and finally uneasiness in the epigastrium, 
coated tongue, &c. The case was cured by leeching and purgatives. 
He mentions another instance still more closely simulating disease of 
the brain. A very singular case is related by M. Hellis, of Rouen. 
The patient, a young man aged about 15, at first felt a dull pain near 
the last dorsal vetebra, which soon extended itself to the epigastrium, 
attended with hiccup. In this situation he continued, with occasional 
intervals of weeks or months, for several years : at last the pains 
did not confine themselves to the back and epigastrium, but darted 
through the chest, abdomen, and down the legs to the toes. It also 
affected the upper extremities, and passed along the course of the 
nerves to the extremities of the fingers. On closing the hand, the 
hiccup and pain would cease, button extending a single finger it 
would appear, and quick as lightning traverse the parts just men- 
tioned."t 

From the foregoing facts, we perceive that neuralgic irritation is by 
no means confined to a few points of attack; and we shall presently 
make it appear that its causes are scarcely less various than the parts 
which are susceptible of becoming its seat. 

Causes and pathology. — Dr. Macculloch strenuously insists on the 
malarious origin of neuralgia, and there can scarcely exist a doubt, 
indeed, that in many instances, neuralgic affections are nothing more 
than masked agues from the influence of koino-miasmata. In mias- 
matic districts, the occurrence of affections of this kind is far from 
being uncommon; and their close affinity to intermittent fever seems 
to be sufficiently demonstrated by the strict periodicity of their cha- 
racter; and the remedies most successful in removing them, being the 
same that are most effectual also for the cure of fully developed inter- 
inittents. The symptoms, too, which on a careful examination may 
be detected in many instances of periodical neuralgia just before the 
accession of the paroxysms, indicate the close alliance between them 

* Rev. Meilicale, Janvier, 1824. 

t Med. Chir. Rev., Oct., 1826. Journal Generate deMed., April, 1826. 



186 NEURALGIA. 

and intermittents. « Immediately before the attack," says Dr. M., "if 
the pulse be examined, it will be found to put on that character which 
it possesses in the cold stage of intermittents, while through the pro- 
gress of the paroxysm it passes through the other analogous changes." 
There are also, most commonly, "some indications of a cold stage, 
generally obscure, it is true, as is the case in most of the anomalous 
and chronic intermittents, but still discernible." There is much rea- 
son to believe that individuals who have laboured under intermittents, 
may afierwards, even at remote periods, have relapses of the dis- 
ease in the form of periodical neuralgia. I have seen two instances 
of this kind, of great severity, which yielded readily to the powers of 
arsenic given during the intermissions. True as it undoubtedly is, 
that many cases of this affection arise from the influence of koiuo- 
miasmata, and partake of the nature of intermitting fever, it is never- 
theless far from being so generally dependent on this cause as is 
alleged by Dr. Macculloch. It is manifest, indeed, from the many 
cases that have been published of late years, that this painful affection 
may be originated by a variety of very distinct causes, some of them 
of a general, and others of a strictly local character. Sometimes it 
appears to be dependent on a morbid irritability and irritation in the 
intestinal canal; and this is probably most commonly the case when 
the affection occurs in the nerves of the mammae, on the side of the 
head, and in the heart, producing angina pectoris. I have seeii an 
instance of excruciating pain and tenderness in the left breast, between 
the nipple and the axilla, without inflammation, swelling, or redness, 
in a lady habitually affected with gastric disturbance. It was removed 
by a course of simple diet, mild tonics, blue pill, aperients, and laxa- 
tive enemata. 

The occurrence of neuralgia from mechanical injury of ilie nerves 
is by no means uncommon. In many instances of this kind, the neu- 
ralgic pains are seated at a distance from the part where the primary 
irritation or injury exists; but in others, the affection is located im- 
mediately in the injured nervous ramifications. Sir Henry Halford 
has lately adduced some observations, which would seem to show 
that facial neuralgia is occasionally excited by lesion of bone. In 
one of the cases he relates, "there was an exostosis of the alveolar 
process — in another there was disease of the antrum high-morianum; 
and in a third, and the most remarkable of all, there was a prodigious 
deposit on the internal surface of the skull, like frost-work, which 
must have caused great pressure on the brain. Dr. Pemberton, pre- 
viously to the development of the neuralgia of which he died, was 
twice affected with abscess in the frontal sinuses."* In a case of 
neuralgia of the face, Dessault found the foramen through which the 
nerve passed in a diseased state. 

Many cases are on record where neuralgia was produced by acci- 
dental injuries, such as wounds, bruises, &c. M. Feron has related 
an interesting instance of this affection, which was produced by a 
bite from a little girl in a state of delirium, inflicted on the back of 

* Med. Chir. Rev., April, 1828. 



NEURALGIA. 187 

the second phalanx of the little finger of the left hand in an old lady. 
In a few days, excruciating pain was experienced in the little finger, 
spreading successively to the hand, forearm, and elbow, along the 
track of the cubital nerve. After cauterizing the wound, the pain 
extended to the axilla, and increased in severity ; at last a sense of 
stricture and fullness or stuffing in the chest ensued, which was soon 
succeeded by violent cardialgia and vomiting. These symptoms, 
recurring in paroxysms, lasted six months.* A most distressing case 
is related, which was caused by a wound of the hand from the explo- 
sion of gunpowder. Amputation of the arm was twice performed, 
but the disease always returned in the stump as soon as it was cica- 
trized. The patient visited Paris, London and Edinburgh, where he 
consulted the most eminent of the faculty, but he derived no perma- 
nent advantage from the measures that were recommended. I once 
saw a case of great violence, which was produced by a fracture of 
the forearm. I have not heard whether the disease was ultimately 
removed or not. Dr. Jeffrey has recorded a very aggravated case, 
which was caused by a wound in the cheek by a piece of chinaware, 
a small portion of which remained imbedded in the wound. It may 
also arise from the irritation of a carious tooth. Mr. Swan has given 
the history of a case of facial neuralgia, which was produced by a 
blow on the right eye. 

With regard to the proximate cause of neuralgic affections, patho- 
logists have expressed a diversity of opinions. Dr. Parry attributed 
the pain to "increased vascularity or determination of blood— per- 
haps amounting to inflammation — of the neurileme or vascular 
membranous envelop of the affected nerves." M. Vaidy, who has 
published a valuable memoir on this disease, entertains a similar 
view of its pathology. He considers all neuralgic affections as con- 
sisting in inflammation of the nervous tissues.! The affected nerve, 
or its neurileme, has indeed sometimes been found preternaturally 
vascular and injected ; yet these conditions may be the consequence, 
and not the cause of the neuralgic irritation. The nerves, says Mr. 
Swan, are liable " to become enlarged and inflamed from irritation, 
just as muscles are from continued action ; but dissection, he says, 
has not shown those depositions of coagulable lymph and structural 
changes which are produced by continued inflammations of the other 
parts of the body, and of the nerves themselves in stumps and por- 
tions along the seat of inflammatory action.''^ The general opinion 
at present is, that this painful affection is frequently the result of mere 
nervous irritation, without any necessary connection with vascular 
congestion or inflammation. Without doubt, however, inflammation 
or increased vascularity of the neurileme may give rise to the dis- 
ease ; and it may, I think, be assumed as a fact, that neuralgia may 
depend on different causes — on local inflammation or congestion of 

* Med. Chir. Rev., Sept., 1821, from the Journal Complement., Mai, 1820. 
t Journ. Complement., Dec, 1820. 

X Dissertation on the Treatment of Morbid Local Affections of the Neryes. By 
Joseph Swan, &c. 



188 NEURALGIA. 

the affected nerve— on organic disease of the brain — and most com- 
monly on a sympathetic irritation, from latent irritation in other parts 
or organs. 

Diagnosis.— The diagnosis of neuralgia is not, in general, attended 
with difficulty, unless it be seated in the internal organs. The pain, 
as has been stated, is darting, extremely acute, paroxysmal, and 
usually transient, coming on with the suddenness of an electric shock, 
and ceasing as instantaneously. These circumstances, together with 
the exceeding aptitude of the slightest touch or motion of the affected 
part to renew the paroxysm of pain, and the entire absence of swell- 
ing or inflammation, and usually of heat in the part, and finally, the 
transient radiations of the pain along the course of the nerves, are 
sufficient to distinguish this disease from other painful affections. 

Treatment. — The mode of treatment must of course be diversified, 
according to the nature of the exciting cause, and the extent and 
situation of the neuralgic affection. A case produced by local injury 
of the nerve will scarcely yield to the same treatment that will be 
required for one which arises from the influence of miasmata ; and 
an instance depending on this latter cause, will probably yield to re- 
medies that would fail in one which originates from gastric irritation, 
and a general morbid irritability of the system. Formerly, consider- 
able reliance was placed on dividing the affected nerve ; but although 
no inconsiderable number of cases have been related, where this 
operation effected a cure, it is but seldom that it can be resorted to, 
on account of the number and situation of the affected nervous rami- 
fications; and where the disease depends on a sympathetic irritation, 
or a local injury nearer the origin of the nerve than can be reached 
with the scalpel, there would appear to be but very little or no chance 
of advantage from this measure. Mr. Swan, in speaking of this 
operation when the portio dura* is affected, says, that the attempt to 
divide the trunk of this nerve is not only attended with much diffi- 
culty, but also with danger ; and " to divide all the branches that go 
to the face, requires an incision from the zygoma to the angle of the 
jaw. The greatest portion may be divided by making an incision 
down to the jaw, a little below the zygoma, and thus the main 
branches of the nerve will be cut through ; and if the patient is not 
relieved by the operation, another incision may be made quite to the 
angle of the jaw, by which nearly all the principal branches will be 
divided." When the disease is located in the third branch of the 

* [The portio dura can never be the seat of neuralgic pains. I have had many 
opportunities of proving the truth of Sir Charles Bell's doctrine upon this subject in 
my observations upon the living body. It is totally insensible to the irritation of 
instruments of every kind, and is purely a nerve of motion, imparting both volun- 
tary and involuntary powers to the muscles of the countenance. When we have 
excited pains in our operations near the trunk of this nerve, they have arisen from 
a disturbance of the superficial temporal, the only sensitive nerve in that vicinity. 
Irritation of the portio dura produces a muscular rigidity or contraction of the 
vessels which it supplies, and division or compression, or simple impairment of 
its energy, produces an atonic muscular paralysis of the same parts. Mo.] 



NEURALGIA. 189 

trigeminus, in which case the pain is felt in the side of the tongue 
and the teeth, the attempt to divide the nerve would be dangerous. 
When, however, the pain occurs in the lower lip, the nerve may be 
divided as it passes out of the lower jaw, by passing the point of a 
knife between the lip and the bone at the first bicuspid, down to the 
foramen, and moving it a little from side to side.* Notwithstanding 
the difficulty and hazard of dividing the trunk of the portio dura, a 
very interesting example of the performance of tlfts operation, by 
Dr. Warren, of Boston, is related in the sixth volume of the Medical 
Recorder. The patient had laboured under the disease for fourteen 
years, and had already undergone the operation of dividing the 
infra-orbital nerve, and the first branch of the trigeminus. The pain 
passed from a point near the ear over the side of the face. "A dis- 
section was made between the back part of the parotid gland, and 
the mastoid process," the nerve exposed and a portion removed. 
The pain nevertheless returned. He now cut down over the side of 
the jaw, through the parotid gland and masseter muscle, removed a 
portion of the bone with the trephine, and exposed the nerve where 
it enters the lower jaw, and removed a piece half an inch long.t This 
completed the cure. 

In cases of neuralgia in the nerves of the extremities, the removal 
of a portion of the affected nerve has been practised with success in 
no inconsiderable number of instances. Mr. Earle has reported a 
case,} where the complaint was cured by cutting out a portion of the 
nerve; and Mr. Abernethy cured a case seated in the integuments of 
a finger, by removing about half an inch of the digital nerve. The 
propriety of removing, instead of merely dividing the nerve, is 
founded, in part, on experience, and on the fact ascertained by Sir 
Everard Home and others, that when a nerve is merely divided, and 
the extremities left close together, they regain the power of transmit- 
ting the nervous influence in a few days. M. Lisfranc cured a case 
of neuralgia of the scalp, caused by an external injury "by removing 
an oval piece of scalp, including the seat of the pain, three inches in 
length and two in breadth."§ The practice of dividing the neuralgic 
nerve has, however, so frequently, we may say, so generally failed, 
that it is now almost entirely abandoned by practitioners. Where the 
disease is confined to a single branch, and arises from local irritation, 
it may, nevertheless, be resorted to with some prospect of success, 
and ought most assuredly to be employed, where all other remedial 
measures are ineffectual. 

In recent cases, depending on a constitutional cause, where the 
paroxysms recur periodically, tonics, particularly quinine and arse- 

* Loc. cit., p. 56. 

t [This last operation divided the inferior sensitive branch of the trigeminus — 
the real seat of the disorder. The first operation on the portio dura, which does 
not enter the lower jaw, was necessarily unsuccessful in the way of relieving 
pain, and could only have produced an incurable paralysis of the muscles. — Mc] 

t Med. Chir. Transact., vol. vii. 

i Med. Chir. Rev., July, 1826. 



ISO NEURALGIA. 

nic, will most frequently remove the disease. Instances of this 
kind, as has been stated, are generally of malarious origin, and will 
commonly yield to the same mode of treatment that is usually 
adopted for the removal of intermitting fever. Indeed, neuralgia 
of this kind sometimes disappears spontaneously, just as intermit- 
tents are known to do, without any medicine. About two years 
ago, I attended a lady labouring under quotidian paroxysms of the 
most excruciating neuralgic pains in the portio dura. The autumn 
previous she had been affected with protracted intermittent, and as 
she had taken a great deal of quinine, which always affected her 
head very disagreeably, she now obstinately refused to take it. I 
therefore directed a blister to be laid on the epigastrium, and put 
her on a very simple farinaceous diet. In three days the neuralgia 
ceased, and has not troubled her since. 

Dr. Macculloch, whose experience in cases of this kind appears to 
have been very extensive, says that the Peruvian bdrk and arsenic 
are decidedly the most efficacious remedies in intermittent neural- 
gia ; and this observation is confirmed by the experience of others. 
Mr. Shaw has used bark with marked success in neuralgic com- 
plaints; and Dr. Kerrison asserts, that, according to his experience, 
cinchona is the most useful medicine we possess in cases of this kind. 
M. Vaidy also cured an instance of facial neuralgia, which came on 
with extreme violence every day at 12 o'clock, and lasted four or 
five hours, by means of the cinchona.* Five or six years ago, I 
met with a few cases of well-marked intermitting facial neuralgia, 
which yielded readily to large doses of quinine ; but in one instance, 
of a strictly quotidian type, which more recently came under my 
care, neither this remedy, nor arsenic, made the slightest impression 
on the disease. Many cases might be collected from recent medical 
publications illustrative of the good effects of tonics in periodical 
neuralgia. MM. Ribes and Dupre have reported an interesting case, 
which was speedily removed by the quinine-^ and M. Piedagnel 
succeeded, in a very short time, in curing this affection with this 
tonic.| Dr. Lalaurie, physician to the Central House of Correction 
at Eysson, has related an instance of neuralgia which originated 
from a puncture of a ramification of the frontal nerve, and which 
had continued for ten years. The attacks came on periodically. 
The patient was ordered to take every morning the sixteenth part 
of a mass, composed of a drachm of white soap and a grain of 
arsenious acid; drinking immediately afterwards three cups of 
water containing mucilage and honey. This was repeated every 
other day, and in two weeks the disease was entirely removed. 
From the observations that have been published, it appears, there- 
fore, that in intermittent, quotidian, or tertian neuralgia, and in 
these only, do the tonics just mentioned manifest any particular 
curative powers; and in all such cases, whether originating from 

* Journal Complement., December, 1820. 
t Magendie's Journal de Physiologie, 1822. 
% Lond. Med. Repository, 1821. 



NEURALGIA. 191 

general or local causes, they ought certainly to be fully tried before 
recourse is had to other modes of treatment. 

No article of late years has attracted more attention as a remedy 
in neuralgia, than the carbonate of iron. Mr. Hutchinson has 
published a small work on tie douloureux, in which he relates a 
considerable number of well-marked cases that yielded to the powers 
of this remedy.* It has also been used with success in this affection, 
by Mr. Richmond,! Dr. Crawford,! Dr. Evans,§ Dr. Brothwick,|| 
Dr. Davis, Dr. Yates, Dr. Ayre, Dr. Marsden, Dr. Payne, Dr. Mar- 
shall Hall, and others. The cases related by Dr. Evans furnish very 
striking testimony of the sanative powers of this article, even in 
very protracted instances, and of great severity. It should be given 
in large doses— from one to two drachms, three times daily. This 
remedy appears to be best adapted to intermittent cases, attended 
with debility of the digestive powers. It is not, however, superior 
to the quinine or arsenic in such cases. I have in several instances 
resorted to it, but only with partial advantage. In one of these cases 
the disease was afterwards removed with the quinine. 

Some of the narcotics, also, have been strongly recommended 
for the cure of neuralgic affections. The stramonium, especially, 
possesses very considerable powers against such pains. It was some 
years ago recommended by Dr. Marcet as a highly valuable medi- 
cine in these and other painful affections unattended with an inflam- 
matory diathesis, and it is unquestionably entitled to much attention 
as a remedy in cases of this kind. Dr. BigbeelT has published a 
paper illustrative of the valuable powers of this article in painful 
affections of the nerves, and we have also the testimony of Dr. 
Elliottson, among others, in favour of its virtues in neuralgic com- 
plaints.** I have employed it in four cases of recent neuralgia, in 
two of which I succeeded, in the course of three or four days, in 
completely removing the disease. One-fourth of a grain may be 
given every four hours, until vertigo is produced, when its use must 
be omitted, and resumed as soon as the vertigo subsides. It has 
appeared to me most effectual in cases attended with, and probably 
mainly dependent on, a general irritable condition of the nervous 
system, or in what may be termed hysteric neuralgic pains. It must 
not be forgotten, however, that when given in repeated and active 
doses, it is very apt to produce a species of maniacal delirium, 
strongly resembling delirium tremens. In two instances, in which 
I prescribed it for chronic rheumatism, it had this effect. The bella- 
donna, too, has had its advocates as a remedy in neuralgic com- 

* Cases of Tic Douloureux successfully treated. By B. Hutchinson. London, 
1820. 
t Lond. Med. and Phys. Journ., No. cclxxi, p. 271. 
X Ibid., 1823. 

$ Edin. Med. and Surg. Journ., Jan., 1824. 
II Ibid. 

If Edin. Med. Chir. Trans., vol. i, p. 285. 
** Med. Chir. Rev., June, 1828. 



192 NEURALGIA. 

plaints ; but its powers as an internal remedy are certainly much 
inferior to those of stramonium in this respect. Mr. Bailey, how- 
ever, speaks very favourably of its remedial effects in affections of 
this kind. He has related thirty cases in which the internal employ- 
ment of this narcotic proved more or less beneficial. He began with 
three grains of the extract, and repeated it in small doses, at short 
intervals, until relief was procured. Mr. Todd states that he has 
cured several cases of painful affections of the nerves, by the exter- 
nal application of a strong aqueous solution of the extract of bella- 
donna to the skin over the affected part. In one instance, where 
the pain was experienced along the course of the sciatic nerve, from 
the hip to the foot, almost immediate relief was procured by rubbing 
the track of the pain with a solution of two drachms of the extract 
of belladonna in an ounce of water. Another instance, of a similar 
character, was gradually removed in the same manner. 1 * Dr. Henry, 
an English surgeon, also has reported a case of this affection, treated 
successfully in this way, and in the Revue Me'dicale, for January, 
1830, Dr. Claret has given the details of six cases of neuralgia, which 
yielded entirely to this treatment. He employed the extract by 
frictions. " Five or six frictions, with the extract of belladonna, 
were sufficient to cure a severe case of neuralgia in the supra-orbital 
nerve." In another case the cure was effected by two frictions; and 
in a third case, one friction, with ten grains of the extract, was suffi- 
cient to remove the complaint.t I have lately resorted to this prac- 
tice in a case of neuralgia in the sciatic nerve, with unequivocal 
advantage.! 

The oil of turpentine, likewise, has been used with success in 
certain neuralgic affections. M. Sedillot§ cured several instances of 
sciatic neuralgia, by administering this article in drachm doses once 
or twice daily; and Dr. Wilson, in a communication to Dr. Johnson, 
states, that " in three cases of neuralgic disease which had lately come 
under his care, a cure was effected by the combination of calomel, 
opium, and the oil of turpentine. 11 A pill, containing from two to 
four grains of calomel, and one or two grains of opium, was given 
each night at bed-time, and next morning one or two drachms of oil 
of turpentine, mixed with a little honey. In each of the three cases, 
a complete and permanent cure was effected by this plan, and in a 
moderate space of time. It is more especially in sciatic neuralgia, 
however, that this article has been found particularly efficacious; 
although it has also been used with success in other varieties of the 
disease. M. Martinet has published a paper on the use of this re- 

* Transactions of the Surgeons-Apothecaries, vol. i, article vi. On the Treat- 
ment of Painful Affections of the Nerves ; arising from Local Injury. By George 
R. Todd, Esq., &c. 

t North Amer. Med. and Surg. Journ., vol. x, p. 194. 

X [The extract of aconitum has of late been much used for the same purposes. 
From its power of benumbing the sensations, it would appear to be especially 
calculated to afford relief in neuralgic pains. — Mc] 

$ Medico-Chir. Review. 



NEURALGIA. 193 

medy in neuralgic affections of the hip and extremities, in which he 
asserts, that of seventy cases, fifty-five were cured by the internal 
administration of turpentine ; and many of these cases had previously 
been subjected to various other modes of treatment, without advan- 
tage.* M. Recamier, of the Hotel Dieu, also speaks in high terms 
of the efficacy of the oil of turpentine in neuralgia. 

Leeching has of late years been employed in neuralgic affections ; 
and from some accounts that have been published, it would appear 
that benefit may be derived from this measure in certain cases of the 
disease. Without doubt, where the malady depends on an inflamma- 
tory condition of the nerve or its neurileme, the local abstraction of 
blood is well calculated to do good ; but it is by no means probable, 
I think, that any advantage can be derived from this measure in cases 
connected or dependent on constitutional causes, and there are in- 
stances on record where it did much harm, as in the remarkable case 
related by Dr. Yeates.t M. Vaidy has reported cases which were 
cured by the application of leeches along the course of the nerve. 
(Loc. cit.) 

Of the local applications that have been employed in this affection, 
moxa is, without doubt, the most efficacious. Larrey relates cases 
that were removed by this remedy ; and Dr. Barras has given an 
account of a case of neuralgia of the spermatic cord, which yielded to 
this application. M. Feron has reported a highly interesting instance 
of neuralgia of the ulnar nerve, which was removed almost immedi- 
ately by the application of moxa, near the elbow. In four or five 
months, however, the disease returned; but the moxa now procured 
only a temporary mitigation of the patient's sufferings. Larrey 
advises that the moxa be applied repeatedly, if the first applications 
afford only partial relief. He has repeated the burning ten or twelve 
times, and followed the pain with the moxa wherever it fixed itself, 
before the disease was completely subdued.J 

M. Vaidy has mentioned a case of neuralgia of the sciatic nerve, 
from the hip to the foot, which was speedily and permanently removed. 
by a tight bandage applied over the whole extremity. Jlcupunctu- 
ration has also been resorted to with success in this painful affection. 
M. Pelletan relates a considerable number of neuralgic cases that 
were completely cured by one or two operations of acupuncture. It 
does not appear, however, that it has yet been employed with success 
in facial neuralgia. In the cases mentioned by M. Pelletan, the 
crural, the sciatic, and the plantar nerves, and in one instance the 
superficial nerves of the chest were affected.§ 

A case of facial neuralgia is related by Mr. Beddingheld,|| in which 

* Revue Medicale, Nov. 1828, p. 222. 

t A History of a severe case of Neuralgia, occupying the nerves of the right 
thigh, leg, and foot. 

X [Blackening the cuticle over the origin and course of the pain with the re- 
peated application of a strong solution of lunar caustic often affords relief.— Mc] 

j Revue Medicale. Janvier, 1825; and Archives Generates, Fevrier, 1825. 

II Compendium of Medical Practice. 
VOL. II. — 14 



194 XEURALGIA. 

the application of cerussa, with the view of paralyzing the affected 
nerve, proved entirely successful. The case was under the direction 
of Sir Astley Cooper, and had previously resisted every other remedy. 
Two scruples of the cerussa, formed into an ointment, were rubbed 
on the affected cheek every morning, about an hour before the pa- 
roxysm was expected. By continuing this application daily for a 
month, the disease was completely removed. 

The application of a strong magnet, also, has, in a few instances, 
promptly removed the pain in neuralgia of the face. M. Alibert, in 
his treatise on materia medica, mentions some examples of this kind; 
and a remarkable case of this kind occurred in my own practice about 
eighteen months ago. A gentleman of this place daily experienced 
the most agonizing paroxysms of neuralgic pain in the ramifications 
of the portio dura.* Quinine, the carbonate of iron, arsenic, and 
belladonna, were used, but without the least advantage. At last I 
sent him a strong horse-shoe magnet, and directed him to keep it 
applied on the side of the face, so as to bring the two poles opposite 
to the meatus auditorius. He did so. In about two hours after the 
magnet was applied, the pain became more severe than ever, so as 
nearly to deprive the patient of his consciousness. Suddenly, how- 
ever, the pain ceased entirely, and I found him calm and cheerful in 
the evening. On the following day the magnet was again applied, 
and the paroxysm was very slight, and not more than one-third the 
usual duration. In the course of five or six days further, the disease 
was wholly removed. Was this a mere coincidence; or did the mag- 
net control the neuralgic irritation? It is certain that intermitting 
neuralgia sometimes terminates spontaneously , and it is possible that 
this may have been the case in the present instance. 

Professor Von Hildenbrand,of Pavia, employs a bundle of metallic 
wires (facts et fills metallicis confectum), not thicker than common 
knitting-needles, firmly tied together, by wires of the same material, 
so as to form a cylinder about four or five inches long, and one inch 
or three-fourths of an inch in diameter. This is applied to the pained 
parts, previously moistened with a solution of sea-salt, when, as he 
asserts, it produces almost instantaneous relief. Occasionally, says 
Dr. Hildenbrand, the neuralgic pain is immediately entirely extin- 
guished, with the accompanying effect of a peculiar sense of emana- 
tion from the spot to which the metallic bundle or brush is applied. 
On withdrawing the brush the pain occasionally returns, but in a 
much less violent degree.! 

* [This pain could not have been seated in the portio dura. I repeat, it must 
have been in the trunk of the superficial temporal nerve which supplies sensibility 
to the parotidial and middle temporal region. — Mc] 

t To illustrate the extraordinary remedial effects of this agent. Dr. Hildenbrand 
relates the following case : " A man aged 30, affected with violent tic douloureux 
of the face, was admitted into the clinical wards of Pavia. On applying the 
metallic brush over the left frontal nerve, the pain immediately disappeared from 
that one, but fixed in the corresponding nerve of the right side, which had been 
previously free from pain. The very moment at which the brush was removed 



NEURALGIA. 195 

Within a few years past, much attention has been directed to the 
origin of the spinal nerves, in neuralgic affections of the trunk and 
extremities of the body. From the interesting observations of Teale* 
and Tate,t it appears, that in many cases of neuralgic pains in the 
chest, abdomen and extremities, much tenderness to pressure exists 
in the region of one or more of the vertebras. They assert that the 
application of leeches, or cups, or as Teale particularly recommends, 
tartar emetic ointment, so as to cause pustulation over the tender part 
of the spine, will very generally speedily remove the painful affection. 
They report some striking cases of the value of this practice ; and 
the recent periodical medical publications furnish interesting testi- 
mony from other sources, in confirmation of their experience. 

An attention to proper dietetic regulations, and to the restoration 
or maintenance of the regular action of the liver and bowels, is of 
much importance in affections of this kind — more especially where 
the disease is attended with manifest symptoms of gastric derange- 
ment.J 

Gaslra/gia.§ — For mitigating or removing this painful and dis- 

from the left frontal nerve, the pain returned to its original seat, and there remained, 
though already greatly abated in intensity. By applying a metallic brush to each 
supra-orbital nerve simultaneously, the original neuralgia of the left side was 
removed, without again appearing in the opposite side." 

If, in cases of this kind, the pain is purely nervous, without inflammatory irri- 
tation or change of structure — in which case its attacks are always periodical with 
perfect intermissions of freedom from pain — " then the efficacy of the metallic 
brush may be pronounced infallible. But if the pain be continuous, or at least 
void of perfect intermissions, or if it is aggravated by pressure, or attended with 
redness, heat and swelling, in short, if there is reason to believe that the neuralgia 
is attended with active congestion or sub-inflammatory irritation, then the metal- 
lic brush will afford no benefit, nay, it may augment the severity of the pain.' r 
Edin. Med. and Surg. Journ., vol. xxxix, p. 492. 

* Teale on Neuralgic Diseases. 

t Tate on Hysteria, &c. 
• X [Dr. Eberle has undervalued the operation of dividing the sensitive nerves, 
which are the actual seat of neuralgia. Before the distinction between the two 
classes of sensitive and motor nerves was understood, surgery often failed in 
consequence of dividing the wrong nerve, as the portio dura instead of one of 
the branches of the trigeminus or the ninth pair instead of the gustatory. When 
they cut on the distal side of the affected part, they also must invariably have 
failed. We now understand this thing better, and are guided in our operations 
by the brightest lights of science. On a proper occasion, I shall take the oppor- 
tunity of publishing the results which have followed my operations in extreme 
cases of neuralgia. — Me] 

$ Although I have already described this affection, I may add the following 
description of its symptoms, as given by Dr. Dawson. <: The time and accession 
of the paroxysm, and the duration of it, are alike uncertain. A hearty meal or a 
copious drink of a stimulating fluid, will sometimes bring temporary relief. The 
pain is aggravated by walking, and slightly mitigated by reclining on the left side 



196 NEURALGIA. 

tressing affection, which appears to be purely neuralgic, various 
remedies have been recommended; but they have seldom afforded 
more than temporary relief. Opium in full doses will indeed always 
procure perfect ease for a time ; and there are few who are much 
affected with this complaint, who do not find it necessary to resort 
to this narcotic. The misfortune, however, is, that those who have 
once experienced the delightful effects of this medicine, when suffer- 
ing under an attack of gastrodynia, will repeat it again and again, 
whenever the pain returns, and as the dose must be progressively 
augmented, the unfortunate sufferer will almost inevitably contract 
a habit of taking it in enormous and ruinous quantities. Dr. Daw- 
son* observes: " It may be said that opium is a great evil ; it is so; a 
most painful necessity ; but it is a far greater evil to pass one half of 
life in excruciating pain, and the other half in miserable anticipation. 
The gastrodynic sufferer has a choice of evils; for him there is no 
middle path ; he must either contentedly endure a pain which makes 
life a burthen, and renders talents useless, or take opium; for where 
is the man, who, racked with pain in the stomach night and day, can 
perform his duties in society, and enjoy life as it ought to be en- 
joyed ?" Unquestionably the effects of large doses of opium in this 
distressing malady are delightful for a time ; but I am by no means 
disposed to regard this drug as the only means in our power for 
procuring relief in cases of this kind ; I have myself suffered much 
from this complaint, and have taken opium in large doses ; but I have 
found another remedy, which is less ruinous in its consequences, 
and far more permanent in its good effects than this narcotic. This 
remedy is the saturated tincture of lobelia inflatu, a few tablespoon- 
fuls of which have never failed to give me speedy relief, and to pro- 
cure me long intervals of exemption from the disease. I have also 
used it in the case of a gentleman in this city with the happiest effect, 
but further than this my experience with this article does not go. 
The oxyde of bismuth, the carbonate of ammonia in conjunction 
with magnesia and mint water, the tincture of henbane, and the sul- 
phate of quinine, with a diet consisting chiefly of animal food, have 
been recommended in this affection, and in some instances considera,- 
ble benefit may no doubt be derived from them. I have prescribed 
the oxyde of zinc in a number of cases, and occasionally with advan- 

and applying pressure by the hand. In some cases the pain is always in the sto- 
mach only : but in others, it does, occasionally, for a short period, quit that organ, 
and, as it were, fancifully and indifferently affects the back, sides of the spine, or the 
integuments covering the sternum and ribs. The pain itself is of a peculiar and 
even of a varying nature. It is not acute, it is not lancinating, it is not spasmodic, 
it is neither sickening nor dragging. It is of an excruciating aching kind, and of 
the most soul-depressing nature. I have known a gentleman lie on the floor in 
agony, and have three distinct attacks, of three, four, or six hours, during twenty- 
four hours. Sometimes the stomach feels empty ; at others it seems distended, 
and gives rise to bitter or saltish eructations. Yet the patient, even on the rack of 
pain, is not ill: and the instant the pain ceases he is as well as he could wish.*' 
* Nosological Practice of Physic, p. 300. 



AMAUROSIS. 197 

tage. Would not the use of the magnet, in the manner recommended 
by Laennec for the cure of angina pectoris, be beneficial in this com- 
plaint? I have just mentioned animal food, as, according to the 
experience of some, (Dr. Johnson,) most proper in cases of this kind. 
This may be correct with regard to some instances; but I have found 
it best to make as great a change of the customary diet of gastro- 
dynic patients as could be done. Thus, if a person has been in the 
habit of using much animal food, he should be put upon a simple 
vegetable diet : and where the accustomed diet has been vegetable, 
which is most commonly the case, it should be changed to one con- 
sisting chiefly of animal substances. It has appeared to me that this 
affection is often connected or dependent on an ineffectual hemor- 
rhoidal effort ; and advantage might perhaps be obtained from leeches 
applied to the anus, and the internal use of small doses of aloes. I 
have been led to this conjecture by the case of a lady in this city, 
who, for six years, suffered from frequent extremely severe attacks 
of gastralgia, radiating along the muscles of the chest, into the left 
mamma. About a year ago, several large hemorrhoidal tumours 
appeared at the extremity of the rectum, and in a short time began 
to bleed freely. The discharge has recurred every three or four 
months, and she has not had an attack of the gastralgia since the 
hemorrhage first appeared. 



Sect. II. — Amaurosis. 

This disease consists in a diminution, or total loss of sight, from 
impaired or abolished sensibility of the retina to the impressions of 
light, or from decreased or lost power in the optic nerve to convey the 
visual impressions from the retina to the sensorium commune. 

This impairment, or loss of sensorial function of the optic nerve, 
and its expansion, may depend either on organic disease of the retina, 
optic nerve, and thalamus, or merely on functional torpor, or palsy 
of these parts, without any perceptible structural lesion. Among the 
organic affections of the optic apparatus which give rise to this 
disease, the following are the principal. Extravasation of blood ; 
opacity; structural lesion, and deposition of lymph upon the surface 
of the retina; fungous or other morbid growths; dropsy, and atrophy 
within the eye ; and all such disorganizations as directly oppress or 
derange the texture of the retina ; and, lastly, morbid conditions 
within the head, oppressing or disorganizing the optic nerve or its 
thalamus — as sanguineous or serous effusions, tumours, suppurative 
destruction in the vicinity of the optic nerve or its origin, and thick- 
ening, atrophy, absorption, or ossification of its sheath.* 

The causes which are capable of suspending or destroying the 
functional power of the retina and optic nerve, independent of per- 
ceptible organic change, are extremely various. Functional torpor 
of the optic apparatus may depend either on vascular turgescence of 

* Travers. Synopsis of the Diseases of the Eye, p. 141. 



19S AMAUROSIS. 

the retina of the sheath of the nerve, or of its thalamus, or on defi- 
cient arterial circulation in these parts; or, finally, it may be the result 
of an idiopathic paralysis, or loss of sensorial power of the retina and 
its nerve. 

When the organic disorder that produces the amaurosis is seated 
in the eyeball itself, several, or all of the following phenomena ac- 
company the disease:— namely, dilated pupil, its contracting power 
being feeble or null; congestion of the veins of the conjunctiva; a bluish 
gray tint of the sclerotica ; loss of regular shape of the globe of the 
eye, the sides either bulging out or appearing flattened ; a turbidity 
or milkiness in the posterior chamber of the eye, " resembling the 
humours in the eye of the horse." In many instances of organic 
amaurosis, a small circular spot of a pearly or greenish-yellow colour 
may be seen at the fundus of the eye, a small distance from the visual 
axis.* When the disease is the consequence of inflammation of the 
retina or choroid coat, and the inflammatory action has entirely sub- 
sided, we usually find the conjunctival veins varicose, the iris dis- 
coloured, thick, very vascular, and inelastic; the bulk of the crystalline 
lens diminished, or liquefied and discoloured, with opacity and deep 
yellow colour of the vitreous humour. ( Travers.) In such cases there 
is usually a feeling of tension, and, at times, of uneasiness, but rarely 
any distinct acute pains in the globe of the eye, and the sclerotica be- 
comes thinner and semi-transparent, admitting the reflection of the 
vascular texture of the choroid coat which occasions the above-men- 
tioned bluish-gray tint of the sclerotica. (Stevenson.) In some cases 
of organic amaurosis, an opaque White spot, or projecting whitish 
substance, may be seen on some part of the concave surface of the 
retina, when the eye is examined in a good light. This constitutes 
the medullary fungus of the retina, which, in the progress of the dis- 
ease, involves the eye in one undistinguishable disorganized fungous 
mass. 

Functional amaurosis, as has just been said, sometimes depends on 
vascular turgescence of the optic apparatus. In such cases the pupil 
is dilated, sluggish in its motion, or immovable ; more or less stra- 
bismus, ptosis, or double vision of the affected eye, often exists ; the 
carotids beat strongly; the face is apt to be flushed; a sense of fullness 
and tension in the globe of the eye is felt, with pain, and a feeling of 
pressure of the scalp ; occasionally ringing in the ears ; disorder and 
irritability of the stomach ; and somnolency. Luminous sparks or 
flashes appear before the eyes, particularly on stooping, straining, or 
on first lying down. (Travers.) These cases sometimes come on 
suddenly. Mr. Stevenson has known several instances, in which the 
patients went to bed apparently well, and awoke with more or less 
complete loss of sight in one or both eyes. 

* " This appearance has been attributed to a circumscribed opacity of the retina, 
answering to the poros opticus. Others have supposed it to be the macula! lutea 
of Soemmering. It is, however, with more propriety, ascribable to a diminished 
secretion of the black pigment/' — Stevenson on the Nature, Symptoms and Treatment 

if Amaurosis. 



AMAUROSIS. 199 

Functional amaurosis from depletion occurs sometimes immediately- 
after excessive hemorrhages, particularly uterine floodings. In this 
variety, as in that which arises from vascular congestion, the pupil is 
dilated and immovable, and there is usually deep-seated pain in the 
head, and occasional vertigo. This pain is attended with a feeling 
of circumscribed pressure on some part of the brain, accompanied 
sometimes with a jarring noise, "like that of a mill or threshing floor." 
In cases resulting from this cause, there exists, in fact, strong vas- 
cular congestion in the head ; for there is no pathological fact better 
established than that strong determinations to the head often supervene 
as the immediate consequence of excessive sanguineous discharges.* 
It is of much importance to distinguish this from the former variety 
in a therapeutic point of view — for amaurosis from excesssive san- 
guineous evacuations is always increased by even small abstractions 
of blood ; whereas that which is attended with a plethoric state of the 
system, demands sanguineous evacuations. 

Symptoms. — Functional amaurosis usually comes on very gra- 
dually. The patient at first complains of some weakness of sight. 
When he looks at small objects, as, for instance, the letters of a book, 
he finds that his vision is variable and irregular — the letters " being 
at one time more distinctly visible than at another, the sight of which 
he alternately loses or regains by shutting or rubbing his ey r es, or by 
moving his head in different directions." Sometimes the approach 
of the disease is announced by a peculiar dimness of sight, as if a fine 
piece of gauze or spider's web were held before the eyes ; at others, 
by the perception of spots, threads, or other imaginary appearances 
floating in the air a short distance from the face ; and at a more ad- 
vanced stage of the disease, coloured spectra, or luminous impres- 
sions of objects remaining upon the retina, often occur. Sometimes 
the objects looked at appear to have a tremulous or wavering motion. 
Connected with these symptoms, there is generally more or less pain 
in the head and temples, diminishing in proportion as the dimness of 
vision increases, and ceasing altogether when the amaurosis is com- 
plete. When the pain continues severely, with but slight remissions, 
and is readily aggravated by whatever excites the system, we may 
presume that it is connected with organic disease within the brain ; 
and such cases are almost invariably accompanied by torpor of the 
bowels; gastric derangement; disposition to lethargy; occasional 
confusion of mind ; indisposition to corporeal or mental exertion ; and 
paralysis in one or more of the muscles. In some cases, very severe 
spasmodic pains occasionally shoot through the eye into the head, 
coming on every night, or second night, about the same time, and 
continuing an hour or two, and are " accompanied with convulsive 
quivering of the muscles of the eye and eyelids, and profuse lachry- 
•mation." 

Some patients affected with incomplete functional amaurosis, see 

* See the observations of Marshall Hall on this subject, in his " Medical Essays/' 
The experiments of Dr. Seeds on the effects of excessive abstractions of blood in 
animals. — Med. Chirurg. Journ., No. vi, p. 107. 



200 AMAUROSIS. 

more distinctly on first awaking in the morning; and in others, the 
sight is clearest in the evening. (Travers.) When one eye only is 
affected, the iris, in functional amaurosis, will generally act in accord- 
ance with that of the sound organ, "provided both be allowed to 
remain open at the same time; but if the latter be closed, the pupil 
of the diseased eye will be found to have lost its power of motion 
on the admission of the usual degrees of light."* In the majority 
of cases, the pupil is dilated and immovable ; and frequently mis- 
shapen or irregular. It is sometimes smoky or clouded, or dark 
gray, or greenish gray, and occasionally of a reddish or yellowish- 
white appearance. 

Diagnosis. — Immobility and dilatation of the pupil furnish no 
certain evidence of amaurosis. In some cases of complete amau- 
rosis, though indeed very rarely, the pupil acts regularly; in others, 
it retains its ordinary size, but is motionless ;t and in others, it is 
fixed and contracted. J Moreover, the ciliary nerves may be para- 
lyzed, occasioning enlargement and immobility of the pupil, without 
amaurosis.§ Among the symptoms which may aid us in distinguish- 
ing amaurosis from cataract, writers particularly mention the dif- 
ferent appearances which the flame of a candle presents to persons 
labouring under one or the other of these diseases. To a person 
affected with the latter disease, the flame of a candle appears as if it 
were surrounded with a uniform thin mist, or white semitransparent 
cloud ; to one labouring under the former affection, an iridescent halo 
seems to encircle the flame, or to emanate from the mist. In imperfect 
amaurosis, the faculty of vision is occasionally increased or dimi- 
nished, "under different states of the circulation, as influenced by a full 
and stimulant meal, by which some find their sight improved, others 
greatly deteriorated. Enlivening or distressing mental emotions, and 
other physical causes, that have a tendency to excite or depress the 
energy of the nervous system, have a correspondent effect in afford- 
ing temporary benefit, or in causing diminution of vision, which does 
not occur in cases of incipient cataract" 

Prognosis. — Those cases which depend on organic lesion, may 
be regarded as incurable ; where, with total loss of sight, the iris is 

* Loc. cit., p. 68. 

f M. Travers is of opinion, that, in cases of complete amaurosis, where the 
pupil is of the natural shape, but motionless, the retina has, most probably, under- 
gone some structural change. 

% When this is the case, says Mr. Stephenson, the disease is generally the 
result of inflammation of the internal ocular textures, and is usually attended 
" with an angular or irregular form of the pupillary border in one or more points 
of the circumference, and with an opacity of the capsule of the crystalline lens." 

$ [I have seen a case in which the solar rays, especially when concentrated by* 
a lens, would dilate an amaurotic pupil to excess. The motions of the iris are some- 
tirnes wave-like or vibrating in cases where amaurosis is supervening. It is an 
excellent rule, which the author has quoted from Travers, to cover the eyes alter- 
nately while the condition of the pupil under the vicissitudes of light is examined. 
— Mc] 



AMAUROSIS. 201 

immovably dilated, or preternaturally contracted, accompanied with 
violent pain in the head, or eye, or cranium, when the disease occurs 
as a consequence of apoplexy, blows on the head or eye, syphilis, or 
protracted internal ophthalmia ; and in cases where the above-men- 
tioned whitish projection appears at the bottom of the eye, little or 
no hopes of a cure can be entertained. 

Where, on the contrary, the amaurosis is not complete, and no 
severe and protracted pains in the head or eyes, or sense of constric- 
tion in the eyeball, accompanies the development of the disease ; and 
where, at the same time, the pupil retains its natural shining black 
colour, and some degree of sight, still remains there is reason to ex- 
pect relief from remedial management. Periodical amaurosis, also, 
unless of very long standing, is of a favourable character; and, in 
general, all those instances of the disease which are purely functional, 
or symptomatic of visceral irritation, or metastasis of gout, rheuma- 
tism, &c, may be regarded as susceptible of being cured. 

Causes. — When amaurosis is not the result of organic or structural 
disease of the optic apparatus, it arises, probably, in most instances, 
from pressure on some portion of the visual nervous texture. Even 
in those cases which occur in consequence of excessive losses of 
blood, vascular turgescence, and pressure of the retina, optic nerve, 
or its thalamus, is, perhaps, the immediate cause of the disease. I 
have already adverted to the great tendency to cephalic congestion 
in that exhausted state of the system which results from profuse 
hemorrhage, and in this state, vascular pressure of this structure may, 
it is to be presumed, readily occur. It may, nevertheless, in some 
instances, depend also on mere functional torpor, from previous over- 
excitation of the retina and optic nerve, or from the vitality of the 
nerve being too much depressed.* 

It would appear, from the observations of pathologists, that persons 
who have dark-brown, blue, or black eyes, are, in general, much 
more liable to amaurotic affections than such as have light-coloured, 
or gray eyes. It has been stated, that the proportion of instances 
of this disease in dark-eyed persons, is to that of the cases which 
occur in individuals with light, or gray eyes, as twenty-five to one.t 

The exciting causes of amaurosis are very various. It may 
depend on metastasis of other affections, particularly of gout, and 
from the sudden suppression of habitual sanguineous or serous eva- 
cuations ; as of the catamenial or hemorrhoidal discharges ; the heal- 
ing up of old ulcers ; and the sudden retrocession of cutaneous erup- 
tions ; and of habitual perspiration of the feet. 

It is sometimes symptomatic of hysterical, epileptic, hypochon- 
driacal, and other nervous affections, (Beer ;) arises from the excessive 
use of narcotics, as well as from the poisonous influence of lead ; is 
the result of abdominal irritation, from a loaded state of the bowels ;% 

* Weller. Manual of the Diseases of the Human Eye. 
t Jahn*s Klinik der Chronischen Krankh., bd. v, p. 295. 
I Dr. Wishart has related an interesting case of amaurosis in the Edinburgh 



202 AMAUROSIS. 

suppressed, or deranged, or excessive secretions in the liver, kidneys 
or uterus ; intestinal worms ; and dyspeptic affections. Sudden mental 
emotions, particularly rage, terror, and protracted grief, sometimes 
produce this disease. The sudden suppression of the secretion of 
milk in the puerperal state has produced it ; and it has arisen from 
rapid and copious salivation ; from excessive venereal indulgence, 
particularly habitual self-pollution ; from intoxication ; and from the 
sudden influence of cold. Among the most common external causes 
of amaurosis, is intense application of the eye to the inspection of 
minute and bright objects,* — which, Mr. Stephenson thinks, tends 
to produce preternatural vascular turgescence in the retina and 
choroid coat. It may also be occasioned by falls or blows on the 
head; insolation; straining in parturition; evacuating the feces; or 
lifting — in short, by whatever is capable of causing preternatural 
sanguineous determination to the head. The occurrence of symp- 
tomatic amaurosis from excessive loss of blood, has already been 
mentioned. Mr. Travers and Dr. Hallt relate some remarkable 
examples of this kind. 

Treatment. — When amaurosis arises from organic diseases of the 
visual organ, or the brain ; or from epilepsy, or in consequence of 
violent forms of fever, and other acute constitutional diseases, nothing 
is to be expected from remedial treatment. The functional or symp- 
tomatic varieties of the disease, however, will often yield under a 
proper course of management. 

The treatment of amaurosis must, of course, be modified accord- 
ing to the nature of the occasional cause ; and the removal of the 
primary irritating cause ought to be the first object in prescribing for 
this disease. Mr. Travers remarks, that the treatment of amaurosis 
is almost entirely constitutional ; and he attaches no value to the 
external application of stimulating vapours, lotions, ointments, and 
ethereal embrocations, &c, although setons, leeching and blistering 
are important auxiliaries. Under this point, however, Mr. Stevenson, 
as well as many others, differs widely from Mr. Travers. The for- 
mer agrees with Mr. Ware in regarding errhines as often particu- 
larly useful in chronic functional amaurosis ; and he thinks favourably 
of the use of stimulating applications to the eye, in cases unattended 
with fever, or local vascular irritation in the eye. 

Medical Journal for July, 1825, which was manifestly the consequence of intes- 
tinal irritation from indurated fecal matter. 

* " Hence the frequency of weakness of sight among the silk-stocking weav- 
ers, milliners, embroiderers, and other mechanics and artists whose occupations 
oblige them to exercise their visual organs with too little intermission and variety, 
in looking intently at their delicate, light-coloured, and highly illumined manipu- 
lations. Persons addicted to read, write, or perform much fine needlework, by 
the aid of candles, and what is much worse, by the brilliant and artificial light of 
lamps, rarely fail, if their organ of vision be constitutionally feeble, to discover, 
sooner or later, the greater or less decay of sight/' — Stephenson, loc. cit., p. 121. 

t Researches, principally relative to the Morbid and Curative Effects of Loss 
of Blood, p. 71. 



AMAUROSIS. 203 

When the momentum of the circulation is preternaturally increased, 
and the eye is somewhat tender and irritable, and particularly when 
the habit is robust and plethoric, the treatment should be commenced 
by both general and local abstractions of blood. " Bleeding, in the 
early stage of acute amaurosis," says Dr. Stevenson, " is the sheet- 
anchor of our hopes. It should be repeated," he says, " at short 
intervals, until the violence of the symptoms shall have been mode- 
rated." 

Immediate attention must also be paid to the bowels. So long as 
the general habit is phlogistic, free purging with calomel, succeeded 
by a portion of Epsom or Glauber's salts, should be practised every 
second or third day, and antimonials, in nauseating doses, adminis- 
tered during the intermediate time. In relation to the employment 
of sanguineous evacuations in this affection, Mr. Travers observes, 
that although obviously proper in cases attended with general ple- 
thora and cerebral compression, yet where the undue determination 
of blood to the eye is attended with diminished tone of the vessels of 
this organ — a circumstance very common, he says, after deep-seated 
inflammation, or irritation and relaxation from over-excitement — 
depletion is always decidedly detrimental. 

In cases of recent imperfect amaurosis making rapid progress, and 
attended with signs of obscure inflammation, the employment of 
mercury, so as speedily to produce soreness of the gums, but not 
salivation, will sometimes suddenly arrest the disease. Mr. Travers 
asserts, that salivation does no good, and may readily prove hurtful. 
" When mercury is beneficial," he says, " its efficacy is perceived as 
soon as the mouth becomes sore." When the pupil shows a disposi- 
tion to contract, or has actually formed adhesions with the capsule of 
the lens, the application of belladonna, or stramonium in solution, to 
the eyes, says Mr. Stevenson, " must on no account be omitted," in 
order to prevent permanent contraction and obliteration of the pupil. 

The light should be excluded from the eyes where there are tender- 
ness and irritability of the organ ; and all kinds of compressing or 
tight bandages be carefully avoided. 

When the local and general excitement has been moderated, or 
where the disease from the beginning is free from manifest general 
vascular irritation, revulsive applications, particularly blistei'ing, or 
a seton on the nape of the neck, and leeching at the temples and 
around the eyes may be resorted to with advantage. In conjunction 
with the occasional employment of these external means, alterative 
and aperient remedies should be regularly used, until there is reason 
to think that the healthy condition of the visceral functions is re- 
stored. For this purpose, a great variety of remedies has been 
recommended, but the use of four or five grains of blue pill, with 
two grains of ipecacuanha at night, on going to bed, and a dose of 
rhubarb, or of the compound extract of colocynth, every second or 
third day, will probably do all that can be effected in this respect.* 

* Schmucker"s visceral pills were formerly much employed in Germany for 
the cure of this disease. They are made according to the following formula: 



>04 



AMAUROSIS. 



Benefit may also be derived, with this view, from the frequent use of 
very minute portions of tart, antimony, dissolved in an infusion of 
sarsaparilla or the root of burdock (arctium lappa). A grain ot this 
antimonial may be dissolved in a pint of infusion, and drank in small 
portions throughout the day. If the visceral functions have been 
brought to a healthy state, and there is an entire absence of general 
and local vascular irritation, recourse should be had to tonic remedies, 
such as arsenic, bark, iron, and the mineral acids. 

The eyes should be kept in a state of repose ; and the patient be 
directed to take gentle exercise in the open air when the weather is 
dry, to use a nutritious but digestible diet, the cold bath, and regular 
rest. 

When amaurosis is strictly chronic, or devoid of general or local 
irritated action, general depletion is not only useless, but frequently 
pernicious. Small abstractions of blood, however, by means of 
leeches, will sometimes be useful, by relieving the local congestion 
in the affected organ. In cases of this kind, much advantage may 
be derived from a seton in the back of the neck, or from the repeated 
application of blisters to that part. To lessen sanguineous conges- 
tion in the eye, some writers recommend the use of errhines, and 
there can be no doubt of their occasional beneficial influence, by the 
irritation they produce in the immediate vicinity of the affected organ, 
as well as the consequent increased discharge from the mucous mem- 
brane of the nose. Some advantage may also, at times, be derived, 
in cases of this kind, from stimulating applications directly to the eye; 
such as the ungt. hydrarg. nitrat., the vapour of volatile alkali; 
weak infusion of capsicum ; vinous tincture of opium, &c. Electricity 
does not appear to possess any particular remedial powers in|this affec- 
tion ; and it is said to be even frequently injurious. Mr. Travers has 
not seen a single instance of benefit derived from electricity. 

Emetics were formerly much recommended in the treatment of 
amaurosis, not only for the purpose of evacuating the stomach, but 
also with a view to their general influence upon the nervous and 
sanguiferous systems. Mr. Travers does not speak favourably of their 
effects in this disease. Richter, on the other hand, gives the most 
favourable account of their influence in amaurosis. That they have 
been employed with success in some instances, is unquestionable; and, 
under peculiar circumstances, may no doubt be again used with 
advantage; although they are certainly not so efficacious as they 
were formerly represented to be by physicians of high authority. 

In complete amaurosis, of a chronic or asthenic character, the 

R. — G. Sagapen. — Galban. — Sapo. venet. aa £i; Pulv. rha3i giss; Tart, emetic gr. 
xvi; Succ. glycyrrh. JjL Fiant. pill, singul. gr. v. Of these pills three are to be 
taken every morning and evening for a month. Richter recommends the follow- 
ing pills: R.— G. ammon.— Assafcctid.— Sapo. venet. — Rad. valerian.— Sumita 
arnicse — 55 gii ; Tart, emetic gr. xviii. Fiant. pill. sing. gr. v. Six to be taken 
thrice daily for three or four weeks. The following combination forms an excel- 
lent purgative for this purpose : R — Massee hydr. gi; G. aloes jjssj Tart, antim. 
gr. ii. Fiant. pill. No. xx. Take one every night on going to bed. 



AMAUROSIS. 205 

German writers recommend exposing the eye to a bright light, and 
even to the direct rays of a meridian sun, with a view of stimulating 
the palsied retina. Mr. Stevenson says, that he has heard of an in- 
stance of the success of this practice; although his own experience 
does not furnish him with an example of its usefulness. Mr. Steven- 
son recommends dry cupping applied to the ball of the eye and its 
appendages. " By carefully fixing a well adapted strong glass, fitted 
with an exhausting syringe upon the edges of the orbit, the instrument 
may be made capable of exerting a more or less powerful influence 
upon the organ of vision, in proportion to the extent to which the 
atmospheric air contained in the cupping-glass is exhausted. The 
effect of this application is to occasion a great redness and tumefaction 
of the eyelids; an immediate distension of the conjunctiva; and a 
bulging forward, or protrusion of the whole globe of the eye, the ob- 
vious tendency of which must be to relieve the deep-seated vessels." 
He mentions a few cases, in which this practice was employed with 
the most decided advantage. 

Dr. Heathcote, of the Royal Infirmary of Edinburgh, has lately 
published some cases illustrative of the good effects of strychnine in 
amaurosis. The cases published by Dr. H., occurred in the practice 
of Dr. Short. The mode in which the strychnine was used in these 
cases, is as follows: A small blister, about the size of a crown piece, 
was applied upon the temple or forehead ; when the part was vesi- 
cated, and the cuticle removed, one-fourth of a grain of strychnia, 
finely levigated, was dusted over the excoriated surface, and a piece 
of simple dressing placed over it. The quantity of strychnia applied 
is to be gradually increased, and the application made daily. Three 
cases, out of about sixteen, terminated successfully under this mode 
of management. In no instance did this remedy cause any injurious 
effects; although slight headache, giddiness and twitching of the 
limbs were experienced by some of the patients. " In one case, 
erysipelas of the face occurred, which immediately subsided upon 
the omission of the strychnia, and the use of opium, which is its pro- 
per antidote." One patient, after about seven grains of the strychnia 
had been applied, was seized with numbness and immobility of the 
lower extremities; but these effects soon gave way to a few doses of 
opium and aperient remedies. We find, also, a statement in the 
London Medical Gazette, of five cases treated on this plan in the 
Westminster Ophthalmic Infirmary. In one case, evident and con- 
siderable benefit ensued.* 

Some modification in the treatment will, of course, always be 
made by the judicious practitioner, according to the occasional cause 
of the disease. Thus, when the disease appears to be the consequence 
of suppressed hemorrhoidal discharge, aloetic purgatives, stimulating 
enemata, and leeching round the anus, are indicated. If it be the 
result of an arthritic or rheumatic diathesis, advantage may probably 
be obtained from the internal use of the tinctura guaiaci, or col- 
chicum, and sinapisms or blisters to the ankles. In instances that 

* Med. Chir. Rev., July, 1830, p. 442. 



206 ASTHMA. 

arise from syphilitic irritation, a slow mercurial course, with infusion 
of sarsaparilla, &c., will be particularly indicated, and the same reme- 
dies are to be relied on where manifest hepatic disorder is present. 
If suppressed perspiration lie at the bottom of the disease, the warm 
bath, diaphoretics, particularly antimonials, both in nauseating and 
emetic doses, will be appropriate means. In short, the practitioner 
should always endeavour to ascertain the cause of the disease, and 
to counteract or remove this cause, if possible, by an appropriate 
course of remedial management. * 



CHAPTER IV. 



CHRONIC AFFECTIONS OF THE RESPIRATORY ORGANS. 

Sect. I. — Asthma. 

Asthma is a paroxysmal affection of the respiratory organs, cha- 
racterized by great difficulty of breathing, tightness across the breast, 
and a sense of impending suffocation, without fever or local inflam- 
mation. 

In the majority of cases, certain symptoms, indicative of gastric 
derangement, precede, often for several days, the paroxysms of the 
disease. Among these symptoms, a sense of weight and fullness 

* [This last sentence in the chapter on amaurosis imparts a valuable hint to 
some practitioners. There is no disease in which the treatment is conducted 
more empirically, or what is called systematically, than amaurosis. Accordingly 
there is not much greater success than in tetanus or even hydrophobia. The plan 
which I have always formed is founded on a careful study of the pathology of 
each particular case. When vascular engorgement attends an amaurotic condition, 
a long continuance in the use of local depletion and derivation will sometimes 
succeed. An over-distended cornea, in addition to diuretics and hydragogues, will 
often require punctures of the cornea to evacuate the humours. I succeeded in 
one case of total amaurosis attended by hydrophthalmia of the aqueous humour in 
the left, and of the vitreous in the right eye, by giving an active course of Clutter- 
buck's elaterium combined with calomel, and occasionally tapping the two over- 
distended humours in each eye. I cured an English gentleman of complete amau- 
rosis in one eye, attended with syphilitic hemicrania and periosteal swellings of the 
scalp, by exciting a smart salivation, aided by the long-continued use of a vapour 
bath and diaphoretic decoctions. Dr. Beesley, of Texas, was restored to tolerable 
vision by the use of lunar caustic to blacken the integuments over the forehead 
and lid, and by the daily use of purgative doses of croton oil. In the case of a 
young lady, after removing a severe form of attendant spinal irritation, and reduc- 
ing the size of her over-distended eyeballs by the use of elaterium, and restored 
perfect vision by the use of electro-magnetic apparatus. — Mc] 



ASTHMA, 207 

in the epigastrium, acid eructations, inappetency or voraciousness, 
heartburn, flatulency, weight over the eyes, anxiety in the prsecor- 
dia, and an itching of the skin, are the most common. 

The paroxysm generally comes on at night during sleep. The 
patient is seized with great anxiety, difficulty of breathing, and stric- 
ture across the breast, and a short dry cough. These symptoms soon 
acquire a most appalling degree of violence. The breathing becomes 
■wheezing, extremely laborious, gasping, and suffocative, the coun- 
tenance expressive of intense anxiety and distress, and the heart 
generally palpitates violently. The desire for fresh and free air is 
inexpressibly urgent ; the patient insists on the doors and windows 
bein°- thrown open ; or he starts from his bed and rushes to the win- 
dow for fresh air, and is wholly unable to remain in the recumbent 
posture. The extremities are generally cool, sometimes of the natural 
temperature, and moist ; the face is bloated and livid or pale, and the 
veins of the neck and head are turgid. The pulse is often irregular, 
intermitting, accelerated, moderately full, and compressible ; some- 
times it is nearly natural, and occasionally it is full, active, and firm. 
After these symptoms have continued for an uncertain time, the 
breathing gradually becomes less laborious and anxious, and towards 
morning a copious expectoration of viscid mucus very generally 
ensues, which always brings with it considerable relief. During the 
ensuing day, the patient usually experiences but little uneasiness or 
oppression in the chest. On the next night, however, the paroxysm 
of suffocative respiration returns; and in this way the disease pro- 
ceeds, with remissions by day, and violent exacerbations at night, 
for three or four days in succession, and in some instances much 
longer, before it finally subsides. 

During the paroxysm, the urine is almost always pale and copious, 
and the abdomen distended with flatus. Breer states that the tem- 
perature of the body is generally considerably below the healthy 
standard. He has found the thermometer placed under the tongue 
as low as 82° during the asthmatic fit. He observes, also, that the 
violence and inconvenience of the paroxysm are equal, whether the 
stomach be full or empty, but that great distress is experienced 
immediately after the fit, if the stomach be completely empty. 
Patients often experience a sensation in the abdomen, about the com- 
mencement of the paroxysm, as if an evacuation from the bowels 
would certainly greatly relieve them ; but this feeling is almost inva- 
riably deceptive. No distinct pain is felt in the chest during the 
asthmatic paroxysm. 

Causes. — Asthma rarely occurs before the age of puberty; yet 
Dr. Gregory states that « the period of youth and manhood is most 
prone to it." If, indeed, we include the acute asthma of Millar, 
or as it is more commonly called in this country, spasmodic croup, 
under the head of genuine asthmatic affections, as is done by most 
of the German writers, there can be no doubt of the correctness of 
this observation ; but the spasmodic croup of children, and the true 
asthma of adults, are manifestly very distinct diseases. It is gene- 
rally admitted, that a predisposition to this affection is sometimes 



20S ASTHMA. 

hereditary. This predisposition would seem to consist in a peculiarly 
irritable state of the pulmonary system, or more correctly, perhaps, 
of the pneumogastric nerve. That this nerve is the seat of that 
peculiar condition which predisposes to asthma, seems probable from 
the circumstance, that in persons who are subject to this disease, 
almost all the organs to which this nerve is largely distributed arc 
particularly liable, from slight causes, to functional derangement. 
Thus, there are few asthmatic subjects who are not especially liable 
to gastric disorders; as indigestion, flatulent colic, and gastralgic 
affections. These facts would appear to show that the pneumo- 
gastric nerve which presides over the functions of the stomach and 
lungs, is in a state peculiarly susceptible of being thrown into morbid 
excitement in asthmatic individuals, and that this condition has pro- 
bably an important share in the predisposition in question. 

Authors have divided asthma into various species, founded prin- 
cipally on the different characters of the exciting or proximate causes 
of the disease. Bree has subdivided the disease into four varieties, 
namely : 1, those cases that are excited by the irritation of effused 
serum in the lungs ; 2, those arising from a gaseous acrimony in the 
pulmonary cells ; 3, those resulting from gastric or abdominal irrita- 
tion ; and 4, those depending on habit. This division is, however, 
altogether arbitrary, as it is manifestly founded on gratuitous prin- 
ciples ; for its dependence on an aerial acrimony in the lungs is a 
mere hypothesis ; and the effused serum in the lungs is an effect, 
probably, and not the cause of the asthmatic paroxysm. It is certain, 
at least, that the difficulty of breathing always commences and con- 
tinues for some time before the effusion of mucus into the bronchial 
cells becomes copious. Richter describes no less than eleven species 
of asthma, founded on the character of its prominent exciting causes, 
namely : Asthma hypochondricum et hystericum; */?. plethoricum; 
A. xirinosum; A. aereum; Ji. abdominale; Jl. nocturnum incu- 
bus; A. metallicwm; A. a causa specijica; Jl. ex debilitate; d. 
spasmodicum; and %fi. acutum periodicum millari. 

Some writers assume only three varieties: — the spasmodic, the 
dry, and the asthma from abdominal irritation. Dr. Good has 
admitted of but two species, namely : the dry ox nervous, and the 
humid asthma. 

Such divisions do not, however, appear to possess any essential 
practical usefulness; and the mere dryness or humidity of the 
cough cannot, I think, be regarded as of sufficient importance to 
form the basis of a pathological distinction. As symptoms, they 
unquestionably deserve attention; and it is no less proper, in a 
practical point of view, to attend to the nature of the exciting 
causes. The judicious and careful physician will not, however, 
require the aid of classification* and subdivisions, to bring these 
circumstances to his attention ; and it may be reasonably doubted 
whether any distinctions not founded on prominent and essential 
points of difference, can be usefully admitted into the description 
and pathology of diseases. 



ASTHMA. 209 

The exciting causes of asthma are — 

1. Particular conditions of the atmosphere, in relation to its 
dryness or humidity, electricity and temperature. In general, 
asthmatic individuals breathe easiest in a pure and unconfined air ; 
but there are many who breathe better in the impure atmosphere of 
populous cities or crowded rooms than in the fresh and. uncontami- 
nated air of the country. Most persons subject to asthma, bear a 
dry and warm air much better than a cold and humid atmosphere ; 
but here, too, the very reverse sometimes obtains in certain individu- 
als liable to this affection. Some suffer most from this disease during 
the warm weather of summer ; whilst others experience its attacks 
only in the winter, or about the autumnal and vernal equinoxes. 

2. Various irritating matters inhaled into the lungs are capa- 
ble of exciting the disease in persons predisposed to it; such as dust, 
and the fumes of lead, arsenic, sulphur, nitric acid, tobacco, and other 
irritating and offensive vapours. 

3. Gastro-intestinal irritation, from indigestible and irritating 
articles of food, vitiated secretions, or a loaded state of the bowels, 
is one of the most common exciting causes of the asthmatic parox- 
ysm. Almost all asthmatic subjects are peculiarly liable to gastric 
disorders from causes of this kind, and even slight irregularities in 
diet are apt to give rise to oppressed breathing in individuals of this 
habit. 

4. The suppression of habitual sanguineous and serous dis- 
charges frequently gives rise to this affection. I have, during the 
last eight years, occasionally attended an old gentleman in whom the 
temporary drying up of a long-standing superficial ulcer on the left 
leg has invariably been followed by violent paroxysms of asthma. 
I have seen an instance in which very distressing asthmatic symp- 
toms alternated with the hemorrhoidal discharge. The suppression 
of the menses sometimes gives rise to nervous or hysterical asthma. 

5. Metastasis of rheumatism and gout, and of various cutaneous 
affections, sometimes gives rise to more or less violent asthmatic 
symptoms. One of my patients, a rheumatic subject, has had seve- 
ral violent fits of asthma during the remissions of his arthritic affec- 
tion. M. Andral mentions an extremely violent case, which was 
produced by the sudden disappearance of a dartrous eruption. 
Leeches and blisters were applied to the part where the eruption 
had disappeared ; and the asthma, by this measure, was completely 
removed in a few days.* 

6. General plethora, in co-operation with causes that produce 
strong sanguineous determinations to the lungs, or increase the mo- 
mentum of the circulation, is particularly favourable to the occur- 
rence of asthma. Individuals of obese and robust habits, florid and 
full complexions, with large and turgid veins about the neck and 
head, are especially liable to asthmatic symptoms from over-exertion 
by exercise, loud speaking, singing, or violent mental emotions. 

7. Cold, when the body is in a state of free perspiration, and par- 

* Med. Chir. Rev., vol. vi, p. 447. 
VOL. II. 15 



210 ASTHMA. 

ticularly suppressed perspiration of the feet, may excite the disease. 
I attended a lady about ten years ago, who suffered exceedingly from 
a protracted and regular paroxysm of asthma, which was brought on 
by bathing her feet in very cold water. She was subject to profuse 
sweating of the feet. 

8. Mental emotions, particularly violent anger and terror, will 
sometimes excite asthma in those who are predisposed to it. 

9. Particular odours and articles of diet, from peculiarity of 
habit, or idiosyyicrasy, may give rise to asthmatic affections in certain 
individuals. Thus the odour of ipecacuanha has excited the disease 
in some persons ; and instances are mentioned in which asthmatic 
paroxysms have been caused by the odour of musk, roses, red beets, 
fresh hay, and sealing-wax. (Parry.) 

10. But by far the most common exciting cause of asthmatic sy mp- 
tojns is organic affection of the heart and aorta. Ossification of the 
cardiac valves, hypertrophy, aneurism of the large arterial trunks 
within the chest, and other organic causes that disturb the action of 
the heart, are rarely wholly free from symptoms of asthma. It is, 
generally, in cases of this kind, that we find the disease to alternate 
with oedema of the extremities, both being merely symptomatic of the 
cardiac affection. 

11. Finally, asthma, like all other paroxysmal, nervous, and spas- 
modic affections, may continue to recur under the influence of what 
Dr. Darwin calls association, or that tendency in the animal economy 
to repeat morbid actions, when once established in the system, with- 
out the renewed application of the original exciting cause. 

Pathology. — Various and very discrepant opinions have been ex- 
pressed with regard to the pathology or proximate cause of asthma. 
Of late years, several French writers* have denied, or at least greatly 
doubted the possibility of asthma, independent of organic disease 
within the cavity of the chest. There can be no doubt, indeed, that 
the majority of cases usually called asthmatic affections, arise from 
causes of this kind, more especially from organic cardiac diseases, 
aneurism of the large arterial trunks, and pulmonary hepatization. 
The occurrence of purely spasmodic asthma, wholly independent of 
obvious structural disorder, is, nevertheless, equally unquestionable. 

In relation to the immediate cause of the dyspnoea in spasmodic 
asthma, there are two doctrines which at present divide the senti- 
ments of pathologists. According to some, the suffocative breathing 
is caused by a spasmodic constriction of the air-cells and smaller 
bronchial tubes, in consequence of which the free admission of air 
into the lungs is greatly impeded. Others believe that the oppressed 
respiration depends on vascular engorgement of the mucous mem- 
brane of the bronchia, giving rise, by the tumefaction of this mem- 
brane, to a mechanical diminution of the bronchial tubes and cells, 
and consequent obstruction to the regular intromission of air to the 
lungs. Laennec, among many others, has adopted the former opin- 
ion, and has endeavoured to prove that the bronchial ramifications 

* Rostan. 



ASTHMA. 211 

are furnished with a coat of circular fibres, beginning where the car- 
tilaginous circles terminate. By the spasmodic contraction of these 
fibres, the air-passages are obstructed, and the phenomena of asthma 
produced. He asserts, that he has " met with many cases, in which 
it was impossible, after the most minute examination, to find any 
organic lesion whatever, to which the asthma could be attributed. I 
am convinced," he says, " that the asthmatic paroxysm may be 
induced equally by the supervention of a fresh catarrh, and by a 
deranged state of the nervous influence, occasioning pulmonary 
spasm, or an increase of the necessity of respiration, and sometimes 
by both causes at once. With the exception of the different kinds 
of catarrh, the occasional causes of asthma and dyspnoea are almost 
always of a kind to give occasion to an immediate and evident dis- 
turbance of the nervous influence. Of this kind are strong mental 
emotion; venereal excesses; the influence of light and darkness; 
retrocession of gout, (a disease which, from its mobility and various 
effects, can only be considered a nervous affection ;) certain odours, 
such as those of the tuberose, heliotrope, stored apples, &c; changes 
of atmospheric air, electricity, and other less appreciable conditions 
of the atmosphere."* 

Mr. Abernethy appears to entertain a similar view of the nature of 
asthma. He contends, that one of the principal causes of this disease 
is a morbid irritability of the mucous membrane of the air-cells. "A 
man," he observes, "having irritable lungs, may be sitting comforta- 
bly enough at the fire-side, but a little smoke comes into the room, 
and he can breathe no more ; he gasps for breath ; he cannot enlarge 
the chest, and he finds the utmost difficulty in respiring ; but where 
is the difficulty ? Where is the sensation of pain and contraction ? 
Why, in the lungs themselves ; the hindrance is there ; I believe it is 
all irritability, and which proceeds from the state of the stomach."t 
Other writers of eminence have declared it as their opinion, that pure 
spasmodic asthma depends immediately on a constriction of the air- 
cells and smaller bronchial ramifications, by which the ingress of 
atmospheric air is impeded or prevented, and suffocative respiration 
produced. It has been objected to this doctrine, that we have no evi- 
dence of the existence of muscular fibres in the smaller branches of 
bronchia and air-cells; but M. Laennec observes that as such fibres 
do undoubtedly exist in the larger bronchial tubes, analogy must lead 
us to admit their existence in the ultimate ramifications. "Besides, 
it is by no means demonstrated," he says, " that muscular fibre is the 
only contractible tissue ; indeed, the contrary is proved by the fact, that 
animals of almost a mucilaginous consistence are capable of evident 
contraction.";); 

We are not, however, without direct evidence of the existence of 
contractile fibres in the minuter bronchial tubes. Professor Nasse, 
of Halle, has published some very interesting experiments on pul- 

* On the Diseases of the Chest, last edition, p. 414. 
t Lectures, p. 375. 
t Loc. cit., p. 408. 



212 ASTHMA. 

monary contraction.* He asserts that in the lungs of sheep, he was 
able, with a good lens, to trace the longitudinal fibres of the internal 
surface of the bronchia, described by Soemmering and Reiseisen.t 
into the smallest bronchial ramifications; and by means of the galva- 
nic influence, he demonstrated the contraction of these fibres in the 
most unequivocal manner: Morgagni has very particularly noticed 
the fibres of the bronchia-^ and although their apparent tendinous 
character would seem to oppose the idea of their possessing contrac- 
tility, yet we perceive that the contractile fibres of the bladder and 
uterus possess a somewhat analogous appearance and structure. 
From the experiments of Nasse, it appears, that the bronchial fibres 
possess considerable contractility; that by passing the galvanic in- 
fluence through the pneumogastric nerves, these fibres, and conse- 
quently the whole lungs, are thrown into a state of contraction; and 
finally, that by dividing the par vaga, the power of pulmonary, or 
bronchial contraction is destroyed, and dyspnoea produced. 

It is highly probable, therefore, that asthma consists essentially in 
a peculiar irritation of the pneumogastric nerves, in consequence of 
which the smaller bronchial tubes and air-cells are thrown into a state 
of spasmodic constriction, by which the regular ingress of air to the 
lungs is prevented. When we advert to the almost invariable ante- 
cedent and concomitant manifestations of functional disorder of the 
stomach in this affection, we have good reason to conclude that the 
nerves which especially preside over the functions of this organ and 
the lungs, are in a state of irritation or morbid excitement. The 
suddenness with which the asthmatic paroxysm is sometimes excited 
by mental emotions and other causes that act directly through the 
nervous system, and above all, the rapidity with which it is often 
dissipated by a few full doses of the lobelia inflata, are directly and 
strongly confirmatory of this view of the pathology of the disease. 
The existence of a constricted state of the ultimate branches of the 
bronchia, dependent, we may presume, on the functional derangement 
or irritation of the pneumogastric nerves, appears, moreover, to be 
confirmed by the good effects which, according to Dr. Chiarenti, 
result from the artificial insufflation of atmospheric air into the lungs 
in this affection.§ 

Dr. Parry, however, considers this opinion of the nature of asthma 
as being without the least foundation, and ascribes the dyspnoea to 
great vascular turgescence of the bronchial mucous membrane, by 
which the smaller respiratory passages are mechanically diminished 

* Undersuchungen iiber die naechste ursache des hustens. Leipzig, 1829, p. 9. 

t Ueber den Bau der Lungen. 

% Extant in tunica intima ceu lacerti quidam insignes ex albicantibus fibrillis 
compacti. Hi digitos aliquot supra asperse arteriae divisionem initium capiunt, et 
secundum ejus longitudinem dispositi, interstitium illud, quod memorabam, tenen- 
les, ubi ad secundum bronchiorum divisionem pervenerunt; ibi primum solent per 
omnem undique bronchiorum superficiem ad istorem extrema versus decurrere. 
Quorum lacertorum usus nunc non existimo. — Adversaria Anatom. Adver., i, $ 25. 

§ Journal de Progress. Vide Med. Chir. Rev., Jan., 1828. 



ASTHMA. 213 

or closed, until the vessels relieve themselves by a copious effusion of 
serum. If, however, vascular congestion be the only or principal 
morbid condition upon which the peculiar symptoms of the disease 
depend, it seems extremely improbable that any impressions made 
on the stomach would be capable of speedily arresting the progress 
of the disease; and yet, in a considerable number of instances, 1 have 
known violent paroxysms of asthma greatly, and in one case com- 
pletely allayed, in less than thirty minutes, by the use of the lobelia. 
There can be no doubt that congestion always takes place to a greater 
or less extent in the vessels of the bronchia and air-cells, after the 
development of the paroxysm; but if this congestion were as great 
as Dr. Parry and others seem to think, is it not very likely that effu- 
sions of blood would occasionally show themselves in the expectora- 
tion? The mere circumstance of the frequent inordinate secretion of 
mucus into the bronchia is no satisfactory evidence that great san- 
guineous congestion pre-existed in the mucous membrane of the lungs. 
It is well known that the process of secretion is wholly under the in- 
fluence of the nerves, and we do no violence to correct physiological 
data, in presuming that the redundant secretion of mucus is deter- 
mined by the irritation of the pneumogastric nerves. 

Prognosis. — An attack of spasmodic asthma seldom proves fatal ; 
and although the frequent recurrence of the disease is apt ultimately 
to give rise to dangerous pulmonary congestions, effusions within the 
chest, and to general exhaustion, it is by no means uncommon to meet 
with persons of very advanced age who have been long subject to 
this disease. 

Where asthmatic symptoms are connected with, or symptomatic 
of, organic pulmonary or cardiac disorder, the prognosis is of course 
always peculiarly unfavourable ; for in such cases, fatal dropsical 
effusion into the cavity of the pleura or the pericardium is almost a 
never-failing consequence of the disease. Spasmodic asthma result- 
ing from mental emotions, or some peculiar odour or vapour, is, in 
general, less obstinate and protracted than those cases that arise from 
gastric irritation, or recur from the influence of habit. 

Treatment. — The treatment of asthma is either merely palliative, 
or radical, according as we prescribe for the mitigation and removal 
of the paroxysm, or the prevention of its subsequent recurrence during 
the intervals of the fits. A great number of remedies and modes of 
treatment have been recommended for palliating or allaying the 
asthmatic paroxysm ; but the effects of remedies of this kind are ex- 
tremely variable in different cases. Some will do much good in one 
person, and fail altogether of procuring relief in an apparently similar 
case in another individual. Nay, the same remedy will in one attack 
afford speedy relief, and fail entirely in another paroxysm in the same 
person. (Laennec.) 

According to the pathology advocated above, the principal indica- 
tions of cure during the paroxysm are to diminish the pulmonary con- 
gestion, and especially to relax the spasm of the bronchial tubes and 
air-cells. Where the pulse is active, and the countenance livid, in 
young and vigorous subjects, blood should be freely drawn; for 



214 ASTHMA. 

although venesection will rarely by itself make any decisive or per- 
manent impression on the paroxysm, its employment is always proper 
in robust and sanguineous habits, to obviate any evil consequences 
that might result from the violent pulmonary and cardiac congestion, 
and as a preparatory measure to the employment of other remedies. 
Professor Potter, of Baltimore, expresses much confidence in the 
efficacy of blood-letting in asthma— more than seems to be warranted 
by general experience. He considers bleeding " not only the most 
effectual remedy" in strong subjects, but in many instances capable 
of effecting a radical cure.* Laennec observes that " we must never 
omit blood-letting, whenever the lividity of the countenance, the 
strength of the patient's constitution, or the over-action of the heart, 
indicates pulmonary congestion; but ive must be careful not to abuse. 
this practice, which, in general, only produces a temporary advan- 
tage." In old persons who have suffered much from the disease, it 
is not in general prudent to abstract blood. It must be observed, 
however, that many writers regard this measure as always of very 
doubtful propriety, and often injurious in its effects. Judging from 
my own experience, I am not inclined to place much reliance on its 
palliative effects, although, for the reasons stated above, I have very 
generally resorted to it, in robust and full habits, without having ever 
known any ill consequences to result from its employment. 

The narcotics have been a good deal employed with the view of 
allaying the asthmatic paroxysm. Laennec has found opium and 
colchicum the most powerful remedies for mitigating and curtailing 
the paroxysm. Articles of this kind, he says, may act beneficially, 
both by lessening the necessity of respiration, and by relaxing the 
pulmonary spasm. Hyoscyamus and stramonium, also, may be used 
with occasional advantage. The latter article, in particular, has done 
much good in several instances of habitual asthma, under my own 
observation. In one case, a quarter of a grain of the extract given 
every four hours for two days, suspended the disease entirely for up- 
wards of nine months. The leaves and roots of this plant, smoked 
in a pipe, will sometimes give much ease to habitual asthmatics ; and 
it is said, that when used in this way, it will sometimes promptly 
mitigate the paroxysms of the complaint. I have prescribed it in a 
few instances in this manner, but never with any particular advantage; 
and writers have mentioned instances in which it proved injurious.! 

In cases attended with catarrhal irritation, and a very copious secre- 
tion of viscid mucus into the bronchia, emetics sometimes procure 
considerable relief. The production of emesis is particularly proper, 
where the paroxysm comes on soon after taking a full meal. It is 
not necessary, nor, in general proper, to excite strong vomiting. Dr. 
Akenside asserts that he has derived as much benefit from nauseating 
doses of ipecacuanha in this affection, as from full emesis. It is gene- 

* Gregory's practice, vol. i, p. 187, second edition. 

t [In France much use is made of the different preparations of belladonna. 
Both the extract and the tincture, especially of the root of the plant, are combined 
with antispasmodics and tonics in the treatment of asthma. — Mc.l 



ASTHMA. 215 

rally admitted that ipecacuanha is decidedly the hest article for this 
purpose. It is said that the union of distilled vinegar and ipecacuanha 
forms a particular useful remedy in this disease. Three grains of the 
latter with three drachms of the former may be taken every fifteen 
minutes, until nausea or gentle vomiting is excited. 

The vinegar of squills, too, has been highly extolled in asthmatic 
affections, both for its emetic and expectorant powers. Sir John Floyer 
considered this preparation as a specific in asthma. He asserts, that 
he has often prevented the paroxysm, by taking a dose of it at bed- 
time. Dr. Bree, also, places much reliance on the powers of this 
remedy; and he observes that its efficacy is in proportion to its emetic 
operation. I have known much relief obtained from this remedy, 
taken in two drachm doses every half hour until nausea was induced; 
more frequently, however, no obvious advantage resulted from its 
use. 

Vinegar is much praised by Bree as palliative in the paroxysm 
of spasmodic asthma. He found it more frequently and decidedly 
beneficial, he says, than any other remedy he had tried. One of my 
patients, affected with occasional paroxysms of this disease, has in 
several attacks derived great relief from two or three tablespoonfuls 
of strong vinegar taken at intervals of half an hour, and from inhaling 
its fumes. In the last two attacks, however, he derived no benefit 
from its employment. 

Bree speaks very favourably, also, of the union of acids and nar- 
cotics as palliatives in the asthmatic paroxysm. He recommends the 
following formula as an excellent combination of this kind.* 

In the asthma of old people, attended with deficient urinary secre- 
tion, and oedema of the feet, diuretics sometimes answer an excellent 
purpose. It is in cases of this kind especially that the squill may be 
used with benefit. In general, a good deal of advantage may be 
derived from diuretics in habitual asthmatic affections. Dr. Ferriar 
speaks well of the powers of digitalis combined with small doses of 
opium in such cases; and Dr. Percival asserts that he has known this 
combination to produce very favourable effects. A copious flow of 
urine is always a favourable symptom in this affection. 

Some writers (Pringle, Percival) speak favourably of the use of 
strong coffee in this affection. I have met with a few individuals 
who derived advantage from its use during the paroxysm. In an- 
other person, however, subject to habitual difficulty of breathing with 
occasional violent fits of dyspnoea, the use of coffee has, of late years, 
invariably aggravated the difficulty of respiration. 

Expectorants may occasionally be employed with some benefit in 
this disease; and for this purpose, the different preparations of the 
squill appear to be the best remedy. I have known the following 

* R.— Tinct. scill. gtt. x. 
Acid, nitric, gr. vi. 
Extract, hyoscyam. gr. iii. 
Aquae fontanss 3iss. — M. This draught is to be repeated thrice daily. 



216 ASTHMA. 

mixture to give much relief towards the termination of an asthmatic 
paroxysm.* 

Antispasmodics do not often produce any good effects ; yet in slight 
cases, considerable relief may be obtained from inhaling the vapour 
of ether; and in old and habitual cases, the aqueous solution of assa- 
fetida has afforded temporary benefit. The only article of this kind 
which I have found to manifest any particular powers, in allaying 
the violence of the asthmatic paroxysms, is the root of the skunk 
cabbage. (Symplocarpus fcetida.) 1 have occasionally employed 
this article in attacks of spasmodic asthma, and in several instances, 
with much temporary benefit. From thirty to fifty grains of the 
powdered root may be taken every two or three hours during the 
paroxysms, according to the urgency and obstinacy of the symptoms. 

Of all the remedies we possess, however, the lobelia inflata is, I 
think, decidedly the most valuable in this affection. Within the last 
five years, I have had an opportunity of witnessing its good effects 
in four cases, and I can truly say, that in two of these it acted like a 
charm. I have known the most violent paroxysms of spasmodic 
asthma completely subdued in less than thirty minutes by this medi- 
cine. It appears to me that ergot does not more certainly act upon 
the gravid uterus during parturition, than the lobelia upon the pul- 
monary organs in asthma. I have even found it to mitigate the 
dyspnoea which occurs in consequence of organic affections of the 
heart. Since the publication of the first edition of this work, I have 
had occasion to prescribe this article in a violent and inveterate case 
of this malady. The good effects, in this instance, were as prompt 
and decisive as in any case 1 had previously witnessed. In one hour 
after the exhibition of the remedy, the patient's respiration was en- 
tirely free from difficulty or oppression. 

The good effects of a full dose of this medicine are often expe- 
rienced in the course of ten or fifteen minutes after it is taken. The 
Rev. Dr. Cuttler, in a violent paroxysm of spasmodic asthma, took a 
tablespoonfui of the saturated tincture. " In three or four minutes," 
he says, "my breathing was free as it ever was. In ten minutes I 
took another spoonful, which occasioned sickness. After ten minutes, 
I took the third, which produced sensible effects on the stomach, and 
moderate puking, with a kind of prickly sensation through the whole 
system, even to the extremities of the fingers and toes. Since that 
time I have enjoyed as good health as perhaps before the first attack."! 
In a case of spasmodic asthma, in which I employed this tincture, 
during the present summer, the dyspnoea was almost entirely allayed 
in fifteen minutes after the first dose was taken. I have not found it 
necessary to give it to the extent of producing emesis, though some 
evidence of its influence on the stomach, as nausea, is desirable. A 

* R. — G. Ammoniac, ^i. solve in 

Acid, scillsc §iss. 

Tinct. opii camp, ^ss.— M. Take a teaspoonful every hour, in a little 
clear and strong coffee, 
t Thacher's Dispensatorj\ 



ASTHMA. 217 

tablespoonful of the saturated tincture may be given every ten or 
fifteen minutes. Within the last two years I have relieved two cases 
of long-standing asthma by ordering a large teaspoonful of the tinc- 
ture of lobelia to be taken upon the first approach of the paroxysm, 
and continued every ten minutes until nausea was occasioned. With 
the nausea the paroxysm immediately subsided. 

A great variety of other remedies have been employed with more 
or less advantage in asthma. The prussic acid was successfully given 
by Dr. Oliver and Dr. Granville. Jilkalies, particularly the carbonate 
of potash, will be proper where there is reason to suspect acidity of 
the stomach. Dr. Bree strongly recommends the use of prepared 
chalk and rhubarb, in combination in cases of this kind — more espe- 
cially after the operation of a gentle emetic. The use of laxatives, 
with some absorbent, will, in general, afford some advantage in 
habitual cases, attended with dyspeptic symptoms, and torpor of the 
the bowels. 

Tonics, also, are said occasionally to produce very good effects in 
protracted cases, attended with much debility and general relaxation. 
The bark is especially recommended by Sir John Floyer. During the 
intervals of the paroxysms, much benefit may, no doubt, be derived 
from this tonic, in individuals of exhausted and relaxed habits, but 
there are few physicians, I presume, who would venture on the ex- 
hibition of this remedy during the paroxysm, except under circum- 
stances especially indicating its employment. 

Dr. Chiarenti, an Italian physician, has lately published a statement, 
from which it appears, that the artificial insufflation of atmospheric 
air, by means of a common bellows, is capable of speedily removing 
the asthmatic paroxysm. " He introduced the pipe of the bellows 
into his mouth, (he was himself affected with the disease,) and closing 
the nostrils, he pushed the air forcibly into his lungs, and with instant 
relief." He afterwards tried the same means in other cases of this 
disease, and always with the same happy result.* 

Galvanism has, of late years, been employed with advantage in 
chronic asthmatic affections, by Dr. Philip and others. The galvanic 
influence must not, however, be communicated with much force. 
The two wires of a weak trough are to be attached, one to a piece of 
metal placed on the pit of the stomach, and the other on the side of 
the neck, over the par vagum. 

With the view of preventing the recurrence of the asthmatic parox- 
ysms, recourse must be had to tonics, a regulated diet, a change of 
air or climate, and regular exercise ; and the usual exciting causes of 
the disease must be carefully avoided. The tonics usually employed 
are bark, quina, arsenic, and the carbonate of iron. Laennec states, 
that he has derived much advantage from the latter article, during 
the intermissions of the disease. Whilst tonics are employed, attention 
must also be paid to the state of the bowels, and the hepatic func- 
tions. An occasional blue pill at night, followed by a gentle aperient 

* Med. Chir. Rev., January, 1828, p. 221. 



218 WHOOPING-COUGH. 

in the morning, the use of the tepid shower-bath, where the system 
is relaxed or exhausted, or cold bathing in robust and full habits, 
together with regular exercise out of doors, change of air or climate,* 
agreeable occupation of the mind, a light and simple diet, and the 
careful avoidance of the usual exciting causes of the disease, are the 
most effectual measures for preventing, or postponing and moderating 
the violence of the attacks. Attention must, of course, be paid to the 
character of the exciting cause in prescribing for asthma, both with a 
view to its palliation and radical cure. When the disease is attended 
with a rheumatic or gouty diathesis, colchicum, diuretics and opium 
are especially indicated. When it succeeds the healing up of an old 
discharging ulcer, blisters and sinapisms to the part are proper. An- 
dral succeeded in curing a violent case by means of this kind. Here 
diuretics, also, are generally peculiarly beneficial. Where catarrhal 
irritation has excited the disease, emetics, the warm bath, squills, and 
opiates, may be resorted to with a good prospect of success ; and in 
cases that depend on gastric irritation, alteratives, the warm bath, 
mild aperients, tonics, and regular exercise, are particularly proper. 
"Among the remedies best deserving notice in asthma," says Laennec, 
" I would mention a mild and spare diet, residence in a more temperate 
climate, and warm bathing. The first of these measures will be found 
very beneficial in cases complicated with gastric irritation ; the two 
last are especially indicated in that class of cases which date from the 
disappearance of cutaneous eruptions, under the use of powerful ex- 
ternal applications."! 



Sect. II. — Whoopiiig-Congh. 

This is unquestionably one of the most remarkable diseases with 
which we are acquainted. A cough, which is highly contagious in 
its nature — which has its regular rise, progress and declension— and 
which completely destroys the susceptibility of the system to a subse- 
quent or second invasion of the disease, is a phenomenon truly mys- 
terious and striking. 

It is maintained by some writers, that whooping-cough is compa- 
ratively a modern disease ; and some assert that it was first brought 
into Europe out of Africa, in the thirteenth century. By consulting 
the works of the ancients, however, it would seem that this disease 

* [It is astonishing to witness the effects of a change of air in many cases. One 
of my patients could never sleep out of town without being seized with aparoxysm 
of asthma; while in the city, he was always in a great measure free from the dis- 
ease. One of my relatives could never visit Philadelphia without an attack. 
Some patients are always worse in the upper stories of a house ; and one old gen- 
tleman was sure to be attacked if he got up as high as the third story chamber 
in either of our cities. Such facts should always be looked after in the selection 
of a suitable residence for every individual afflicted with this distressing com- 
plaint. — Mc] 

t Loc. cit., p. 419. 



WHOOPING-COUGH. 219 

was known at a very early period of our science. Hippocrates, in 
the 6th book on Epidemics, and also in the 6th section of his Apho- 
risms, speaks of a cough, which, from a short description he gives 
of it, may, I think, be regarded as the same affection which is now 
known under the name of whooping-cough. The first distinct and 
comprehensive description of this malady, however, was given by 
Mezeray, in the year 1414, in his Chronological History of France. 
Since that time, a great many epidemics of this disease have been 
circumstantially recorded ; and medical literature furnishes us with 
no inconsiderable number of elaborate monographs on its nature and 
treatment. 

Whooping-cough usually commences with the symptoms of ordinary 
catarrh. The patient at first experiences some degree of lassitude, 
headache and sneezing, with a slight hoarseness, and occasional op- 
pression of breathing. The sleep is generally disturbed by dreams 
and sudden starts ; the appetite becomes weak, the bowels torpid, and 
the pulse slightly febrile towards evening. For the first two or three 
weeks the cough is almost always dry and ringing; and the paroxysms 
are short, and free from that peculiar sound which is called whooping. 
At the end of this time the disease begins to assume more of a con- 
vulsive or spasmodic character, so far, at least, as the mere cough is 
concerned. The paroxysms of coughing nowcome on more frequently, 
and are of longer duration than previously. The inspirations during 
the fits of coughing are extremely difficult, slow, and stridulous, and 
attended with a sense of obstruction or spasmodic stricture of the 
glottis, rendering the paroxysms distressingly suffocative, and, in a 
manner, convulsive. 

The approach of a fit of coughing is generally announced by a 
peculiar sensation of tightness in the breast, and of titillation in the 
larynx and prgecordia. These circumstances should be borne in mind, 
for they throw considerable light on the pathology of this remarkable 
affection. The duration of the fits of coughing is very various. In 
some instances, the paroxysms are generally over in less than half a 
minute; in others, they last from five to six minutes, and often longer. 
The spell of coughing at this stage of the disease, is always terminated 
by the discharge of a large quantity of viscid mucus; and the patient 
frequently experiences some pain in the chest immediately after the 
cough has subsided. In many cases, the cough continues until vo- 
miting comes on, when it is immediately arrested, and the patient is 
greatly relieved. So violent, in some instances, is the fit of coughing, 
that it induces a state of partial insensibility, and a most distressing 
sense of impending suffocation. Occasionally, the determination of 
blood to the head is so great, during the paroxysm of coughing, that 
it bursts out from the nose and mouth ; and it is not uncommon for 
children to become convulsed, in consequence of the cerebral com- 
pression from this cause. In this aggravated state, the disease usually 
continues from four to six weeks, before it begins to abate. The 
declension is always very gradual, continuing commonly from two 
to four weeks. Fever is not essentially connected with the disease, 



220 WHOOPING-COUGH. 

although in many instances there is a manifest febrile irritation pre- 
sent during some period of the complaint. 

Whooping-cough occurs almost exclusively during childhood. I 
have nevertheless met with two instances of the disease in subjects 
beyond the fiftieth year of age, and several in persons beyond the 
thirtieth and fortieth year. It is highly contagious, and occurs almost 
universally in an epidemic form. I have never yet met with a spo- 
radic case of this affection, although it cannot be doubted that such 
instances do occasionally occur. It would seem as if there existed 
some latent connection between the contagions of whooping-cough 
and measles; for the former frequently prevails most extensively, 
either immediately previous, or in alternation, or directly after the 
occurrence of epidemic measles.* Spring and autumn appear lo be 
most favourable to the occurrence of whooping-cough, and it is 
during the wet and variable periods of these seasons that the disease 
is most liable to become dangerous, from the pneumonic affections 
which atmospheric vicissitudes are so apt to produce. As is the 
case with all other epidemic diseases, considerable diversity occurs 
in the grade of violence which different epidemics of this affection 
assume. Some epidemics are so mild, that the disease is attended 
with but little difficulty, and passes by numbers who are still sus- 
ceptible of it. At other times the disease manifests a violent and 
dangerous character, and seizes on almost every individual, whether 
old or young, who has not yet had the disease. 

Prognosis. — Whooping-cough rarely terminates fatally, unless by 
the supervention of bronchitis, hydrocephalus, pneumonia, cynanche 
trachealis, apoplexy, or marasmus. As these secondary and super- 
added affections are, however, by no means uncommon — especially in 
variable and humid seasons — the disease, upon the whole, deserves to 
be regarded as one of considerable danger. It would appear to be 
a vastly more dangerous affection in northern or cold climates than 
in the mild and equable regions of the middle and southern latitudes. 
Rosenstein states, that in Sweden there were 43,393 deaths from this 
disease, between the years 1749 and 1764— and of these, 5832 deaths 
occurred in the year 1755 alone. (Richter.) 

In general, the younger the patients, the more apt is the disease to 
terminate fatally. Cullen observes, that by far the greater number 
of those who die of this disease, are children under three years of 
age. When it attacks weak and delicate infants within the first few 
months after birth, it is always attended with great danger; yet 
robust and healthy infants, even at this early age, generally pass 
through the disease without much difficulty or danger. 

In children born with a scrofulous diathesis, whooping-cough is 
exceedingly apt to call the strumous affection into action. Scrofu- 
lous ophthalmia, and glandular tumours in the neck, frequently suc- 
ceed whooping-cough. I know of no disease which is more to be 
dreaded than whooping-cough in subjects of an hereditary consump- 
tive habit. Where there is a predisposition to the formation of 

* Richter, Specielle Therapie. 



WHOOPING-COUGH. 221 

tubercle?:, or where these exist in an incipient and dormant state, 
an attack of whooping-cough will rarely fail to develop phthisis pul- 
monalis. 

In many instances, the disease terminates in chronic bronchitis, in 
which case the expectoration becomes purulent, and symptoms of 
hectic supervene. This is especially apt to occur when the patient 
takes cold from exposure to a damp and variable atmosphere — a 
circumstance which always greatly aggravates the violence and 
danger of the disease. I have seen but few deaths from whooping- 
cough which were not attended with bronchitis, purulent expecto- 
ration, and hectic symptoms, from having taken cold. The matter 
expectorated in these cases has generally a very peculiar appear- 
ance, resembling more a mixture of cream and mucus, than any 
thing else I know. 

In some instances, an accidental cold will renew the cough, and 
protract it for several months, in a state of great violence, after it 
had nearly disappeared. Cases are often thus protracted for five or 
six months. When the disease assumes a chronic character, from 
cold or some other casual circumstance, it sometimes ultimately ter- 
minates in hydrocephalus — more especially if the patient labours 
under the irritation of difficult dentition, and in children habitually 
subject to disordered bowels. Cynanche trachealis, also, frequently 
supervenes during whooping-cough, and this is most apt to happen 
in children of robust and full habits, during the early stages of the 
disease, and is almost always the consequence of cold. The occur- 
rence of cynanche in this affection is attended with the greatest 
danger. 

It is observed by Richter, that a profuse watery diarrhoea coming 
on suddenly in this disease, when pneumonic symptoms attend, is 
always to be regarded as one of the most dangerous occurrences. 
Death, he says, often follows such a discharge very speedily. The 
appearance of aphthae in the mouth and fauces, in the latter period 
of the disease, is also a very unfavourable sign. (Edematous swell- 
ing of the feet and face is not an uncommon occurrence in this 
affection, and when it takes place towards the conclusion of the com- 
plaint, it is rarely followed by unfavourable consequences. When 
such swellings supervene in the commencement of the disease, how- 
ever, they portend much danger— more especially if they are accom- 
panied with a turbid, milky urine. (Richter.) Hufeland observes, 
that the occurrence of some degree of strangury in the advanced stage 
of the complaint, is generally soon followed by a manifest mitigation 
of the symptoms of the disease. A sudden cessation of the cough, 
it has been remarked, is an unfavourable occurrence, and is frequent- 
ly followed by pulmonary inflammation. In general, the more fever 
there exists in this affection, the more violent and dangerous it may 
be considered. 

It is asserted by some writers, (Hufeland, loc. cit., p. 420; Lentin, 
Memorabilia, p. 36 ; Jahn, Kinderkankn., p. 399,) that children af- 
fected with some chronic cutaneous affection, as tinea, itch, &c, very 
rarely take this disease ; and if they do become affected with it, they 



222 WHOOPING-COUGH. 

almost invariably pass through it in the lightest manner. This, how- 
ever, is contradicted by others — particularly by Hoffman and Haase. 

Among the affections which are properly called sequela of this 
disease, the following are the principal. Strumous swellings, dropsy, 
epilepsy, ophthalmia, rickets, general cachexy, aneurism, deafness, 
dementia, paralysis, and phthisis pulmonalis. I have known most of 
these affections to occur as consequences of whooping-cough ; and of 
these, epilepsy, struma, phthisis pulmonalis, and ophthalmia, appear 
to be the most common. When these and other consequences are 
taken in view — and they are by no means uncommon — we cannot 
but regard this disease as always one of very serious import. Whoop- 
ing-cough is indeed as much to be dreaded on account of the many 
affections which are apt to supervene during its course, or to remain 
after its disappearance, as for its own proper power, however violent 
it may be. When perfectly free from any adventitious complications, 
it cannot be regarded as a disease of much danger, unless in very 
young and feeble subjects. 

Causes. — There exists no other cause, so far as we know, capable 
of producing this affection, than the peculiar contagion which is 
generated by the disease itself. Richter observes, that besides this 
contagion, cold in conjunction with humidity, may give rise to this 
affection. For this opinion it does not appear that there exist suffi- 
cient grounds ; and it seems to me just as improbable, as that small- 
pox or measles should arise from accidental causes. It may be said 
that all these diseases must have primitively originated from acci- 
dental causes — for the first case could not have arisen from a conta- 
gion generated by the disease itself. Nothing, in truth, is more 
mysterious and incomprehensible than the origin of those diseases 
which we now find to be engendered and propagated by a specific 
agent alone, elaborated by the living body actually suffering under 
the disease. The only solution we can offer, and it is indeed vague 
enough, is, that in the infinite combinations of which the material 
elements of the universe are capable, agents may have been evolved 
by a peculiar concurrence of circumstances, which had the power of 
originating these affections in the human system. It is in this way 
alone that we can give any plausible explanation of the occasional 
rise of new diseases— which, when once originated, propagate them- 
selves by elaborating their own specific causes. Whatever may be 
our speculations in relation to this curious and interesting subject, 
the cause of whooping-cough, so far as we can ascertain, is in all in- 
stances a specific contagion. 

Riverius, Linnaeus, Dessault, Rosenstein, and more recently Clesius, 
maintain that whooping-cough is produced by the inhalation of mi- 
croscopic animalcula. 

W T hooping-cough does not appear to possess a contagious character 
until it has made considerable progress, (Richter ;) or until the second 
or convulsive stage has supervened. The contagion of this disease, 
although very active, does not extend far from the body of the af- 
fected person. It is accordingly almost always prevented by separat- 
ing the healthy from the affected portion of families. 



WHOOPING-COUGH. 223 

Jlutopsic phenomena. The appearances discovered on post-mor- 
tem examination are various, and often quite contradictory. Much 
diversity must necessarily result in this respect from the various 
accessory affections which are so common in this complaint, and the 
different periods of the disease at which death occurs. We cannot, 
for instance, expect to find the same post-mortem appearances in a 
case which terminates fatally in consequence of pneumonia, as in 
one in which death occurs from apoplexy ; nor is it reasonable to 
presume that there should be much uniformity in the autopsic phe- 
nomena, where the immediate cause of death is so various, or de- 
pendent on such a diversity of accidental affections. As the respi- 
ratory organs are the parts most obviously implicated in the disease, 
the principal attention of pathologists has of course been always 
directed to them for a solution of the pathological character of this 
affection. Many writers speak particularly of the frequency of traces 
of inflammation in the mucous membrane of the bronchia and larynx. 
Strong, Cullen, Astruc, Lettson, and Danz, mention these appear- 
ances as by far the most common; and more recently, Whatt and 
Marcus have adduced striking instances of this kind. The former lost 
three of his own children by this disease, and in each, the marks of 
previous inflammation in the mucous membrane of the bronchia were 
very conspicuous throughout its whole extent. Marcus gives but 
two dissections in which bronchial inflammation was discovered; and 
in one of these a considerable quantity of pus was found in the air- 
passages, the smaller branches of which were in the most intense state 
of inflammation, approaching, in some parts, to gangrene. 

In some instances, the lungs have been found exceedingly congest- 
ed, and the air-cells choked up with an extremely viscid mucus with- 
out any traces of bronchitis whatever. Lobenstein-Doebel relates an 
instance in which a considerable portion of the diaphragm was covered 
with a number of small pustules containing a purulent fluid.* 

After all, it is incontestable, that in many cases of death from this 
disease, no morbid appearances whatever were discovered on dissec- 
tion, and there are good grounds for believing, that the inflammation 
and other phenomena which have been detected on post-mortem 
examination, have no essential connection with the disease, but are 
altogether adventitious or secondary. 

Proximate cause. — The opinions that have been advanced con- 
cerning the nature or proximate cause of this disease, are extremely 
various and contradictory. Hoffman considered it as depending on 
an acrid serum in the lungs. Sydenham ascribes it to the effects of 
irritating effluvia, cast off from the blood into the lungs, in conse- 
quence of the suppression of the insensible transpiration by the skin, 
from cold and damp air. Huxham and others placed the primary 
seat of the disease in some morbid condition of the intestinal canal ; 
Butler, in the liver ; and some have considered it as the consequence 
of gastric irritation, or, according to Stoll, of crude and bilious mat- 
ters in the stomach. The opinion which appears to be most pre- 

* Richter's Specielle Therapie. 



224 WHOOPING-COUGH. 

valent, at the present day is, that the disease depends on a peculiar 
bronchial inflammation ; and this doctrine would seem to receive 
much support from the appearances which are occasionally detected 
in the mucous membrane of the bronchia and trachea on post-mor- 
tem examination, as well as from the febrile movements which, in 
most instances, attend the disease. As, however, ordinary bronchial 
inflammation does not excite the train of symptoms which charac- 
terize this disease, the advocates of this doctrine are forced to assume 
the position, that the inflammation in question is of a specific kind, 
capable of exciting the peculiar convulsive cough which distinguishes 
the disease. Whatever plausibility this doctrine may seem to pos- 
sess on a superficial view of the subject, strong, and in my opinion, 
insurmountable objections may be urged against its validity. It is 
true, indeed, that fever is no uncommon attendant of this disease, 
and that unequivocal cases of inflammation are sometimes manifested 
on post-mortem examination. It is, nevertheless, equally true, that 
in many instances no febrile symptoms whatever occur during the 
early period, and occasionally none during the whole course of the 
disease ; nor are the signs of previous inflammation in the respira- 
tory passages always manifested on autopsical examination. That 
inflammation must frequently supervene in the trachea and bronchia 
in a disease in which the lungs are so violently and frequently 
agitated as they are in the present one, is indeed to be expected. 
Besides this accidental source of pulmonary inflammation in whoop- 
ing-cough, there can be no doubt that the lungs are especially pre- 
disposed, by the same circumstance, to the injurious influence of 
atmospheric vicissitudes, and consequently to the supervention of 
pulmonary catarrh, or bronchial inflammation. 

From these circumstances, we have the strongest ground for be- 
lieving that the inflammation which is frequently detected on dissec- 
tion in the mucous membrane of the respiratory passages, is always 
accidental, and by no means essential to the perfect development of 
the disease. It may be observed, moreover, that bronchial inflam- 
mation is probably far from being so common in this disease as one 
might be led to think from the appearances discovered on dissection; 
for it must be recollected, that death occurs chiefly in such instances 
only as are attended by unequivocal symptoms of inflammation, and 
we may, therefore, reasonably expect to find traces of inflammation 
in such cases, although in the milder instances no such inflammatory 
condition may exist. If, however, bronchial inflammation be the 
proximate cause of the disease, it must, necessarily, be present in all 
cases, in the mild as well as in the violent instances of the malady, 
a circumstance which is decidedly contradicted by almost universal 
observation. The only dissection I ever witnessed of a subject that 
had died of this disease, presented no evidence of the existence of 
previous inflammation in the bronchia. The patient died suddenly 
of convulsions during a violent paroxysm of coughing. That in- 
flammation of the mucous membrane of the bronchia is not essential 
to this disease, or its proximate cause, is proved, moreover, by the 
fact, that bronchitis is rarely, if ever, attended with a violent cough, 



WHOOPING-COUGH. 225 

much less with that peculiar cough which distinguishes this disease. 
Bronchitis, too, in its acute form, is always rapid in its course, and is 
attended with strong fever and a continued sense of tightness and 
oppression in the breast. In the chronic form, the expectoration is 
invariably purulent, and entirely distinct in its character from the 
ropy and transparent mucus which is expectorated in whooping- 
cough. It is also almost invariably attended with the usual symp- 
toms of hectic fever. When cough depends on acute inflammation 
of the respiratory passages, it almost always begins to decline as 
soon as the secretion of the bronchial mucus becomes copious. In 
whooping-cough, however, the reverse very generally obtains. Dur- 
ing the first few weeks, there is seldom much mucus secreted in the 
bronchia; but as soon as this secretion becomes more abundant, 
which occurs after the second or third week, the cough also acquires 
much more violence, and especially that convulsive character which 
distinguishes it from other varieties of cough. Very commonly, 
moreover, the slight symptoms of fever which accompany the deve- 
lopment and first few weeks of the disease, vanish entirely in the 
second stage, when the cough becomes more spasmodic and violent 
in its paroxysms. (Richter.) This circumstance most assuredly 
does not favour the idea, that the disease is of an inflammatory cha- 
racter ; for if this were the case, the cough, one should think, would 
decline with the fever; instead of which, it is always found to 
acquire much more violence. 

It appears to me that whooping-cough is essentially a spasmodic 
or nervous affection, the proximate cause of which consists probably 
in a peculiar irritation of the eighth pair, or pneumogastric nerves. 

If we attend closely to the phenomena which immediately pre- 
cede and accompany a paroxysm of whooping-cough, we cannot but 
perceive unequivocal manifestations of a purely spasmodic condition 
of the respiratory apparatus. The sense of stricture in the breast 
and of the glottis, which is felt immediately before the fit of coughing 
—the sudden and convulsive character of the cough — the peculiar 
constrictive feeling in the proecordia — the stridulous respiration, all 
point to a spasmodic state of the pulmonary system. That the irri- 
tation which calls forth the convulsive action of the diaphragm, and 
the other parts immediately concerned in the act of coughing, is seated 
in the eighth pair of nerves, may, I think, be inferred from the known 
agency which these nerves have in the production of the various 
phenomena manifested by the respiratory apparatus. The interest- 
ing experiments of Professor Nasse also afford strong support to 
this opinion. In a series of experiments, instituted for the purpose 
of elucidating the pathology of cough, this experimenter found that, 
on bruising or strongly pinching the par vagum so as to break down 
its structure, a violent convulsive cough was invariably excited. By 
injuring in the same manner the diaphragmatic nerve, no such effect 
ensued. According to these experiments, the act of coughing is per- 
formed almost wholly by the sudden spasmodic contraction of the 
diaphragm. J5y opening the abdomens of various animals, and ex- 
posing the lower surface of this muscle, he saw distinctly its violent 

VOL. II. — 16 



226 WHOOPING-COUGH. 

convulsive contractions during the cough, which was excited by 
bruising, with a pair of forceps, the pneumogastric nerves. The 
peculiar tone of the cough, and the sense of constriction which is 
felt at the glottis, may arise from the irritation extending to the recur- 
rent branches of the vagus nerve ; and that this irritation is peculiar 
or specific in its character, may be inferred from the nature of its 
exciting cause. 

Treatment. — It is very generally believed, that whooping-cough, 
though susceptible of much mitigation, is wholly uncontrollable in 
its progress, and that no treatment is capable of materially short- 
ening its course. This, I am persuaded, is an unfounded opinion. 
Sydenham, Werlholf, Hufeland, and several later German, Italian, 
and French writers, admit that it may be arrested in its course; but 
it is asserted, that this can never be done before the fourth week 
after its commencement. (Richter.) Be this as it may, my own expe- 
rience does not permit me to doubt of its susceptibility of being cur- 
tailed in its progress ; and many well-authenticated observations in 
confirmation of this fact, might be collected from recent publications. 

Although inflammation and fever do not constitute essential con- 
ditions of this disease, yet blood-letting may often be employed in 
the first stage of the disease with manifest advantage. An unusual 
or preternatural momentum of the circulation is not to be regarded 
as a harmless circumstance, even in diseases strictly spasmodic. 
Whatever may be the essential character of a disease, if the pulse is 
full and active, blood-letting may be regarded as proper, and its 
employment will generally be productive of some benefit. In the 
present disease, if the abstraction of blood should even afford no 
direct advantage over its characteristic symptoms, it tends materially 
to lessen the danger which may result from the violent cephalic con- 
gestions during the paroxysms of coughing, as well as to diminish 
the liability to the accidental supervention of inflammation. In cases 
attended with bronchial or pneumonic inflammation, bleeding is 
obviously indispensable; and should be employed promptly and 
decisively both in a general and local way. To tamper with the 
ordinary remedies in cases of this kind, would be exposing the patient 
to great danger; for, when inflammation supervenes, it is this, and 
not the original disease, which claims our principal attention, since 
the danger and obstinacy of pulmonic inflammation must be espe- 
cially great in an affection which, like the one under consideration, 
keeps up so constant and violent an irritation of the respiratory 
organs, by the frequency and violence of the cough. Leeching on 
the breast is particularly valuable in cases of this kind. 

The extensive sympathetic relations which subsist between the 
intestinal canal and the various organs of the body cause it to par- 
ticipate, in a greater or less degree, in almost every form of disease 
to which the human system is liable. Whatever be the nature of 
the malady, and in whatever system of structure it may be princi- 
pally located, the alimentary canal, sooner or later, suffers functional 
disturbance, giving rise either to a remora of its recrementitious con- 
tents, or to a vitiated secretion of the fluids which are poured into 



WHOOPING-COUGH. 227 

it. These latter consequences become in their turn sources of intes- 
tinal irritation, and I need not say how great a tendency such irrita- 
tion has to aggravate and sustain diseases, whatever may be their 
original source or character. 

The bowels are almost always in an unnatural condition in whoop- 
ing-cough. The evacuations are sometimes bilious, or almost wholly 
mucous; and, in many instances, dark and exceedingly offensive 
stools are passed. In prescribing for whooping-cough, it is of much 
consequence, therefore, to attend to the condition of the bowels, and 
to keep them in a moderately loose state throughout the whole course 
of the disease. Very active purging, however, is improper, as it 
tends to increase, rather than to moderate the intestinal irritation 
when frequently repeated. A grain or two of calomel in the evening, 
with a small dose of rhubarb on the following morning, will in gene- 
ral answer very well for this purpose. When there is considerable 
febrile irritation present, small doses of the sulphates of soda or mag- 
nesia may be preferable. 

Emetics constitute an important class of remedies in the majority 
of pulmonary diseases. They are especially indicated in those affec- 
tions of the respiratory organs in which there is an abundant secre- 
tion of bronchial mucus. Much of the suffocative distress experienced 
by patients affected with whooping-cough, arises from the large 
quantity of viscid mucus which is lodged in the trachea and bron- 
chia ; and it is chiefly by effecting the discharge of this impediment to 
free respiration, that emetics prove serviceable in this disease. It is 
not improbable, however, that a part of their beneficial operation 
may depend also on the impression which they produce on the 
pneumogastric nerves in the stomach. They are particularly useful 
in the whooping-coughs of infants; these are unable to throw off the 
viscid mucus that clogs the respiratory passages ; and instances of 
death by suffocation from this cause have frequently occurred. When, 
therefore, the cough in very young children is violent, and attended 
with symptoms of impending suffocation, an emetic should be imme- 
diately administered; or the fauces irritated with a feather, so as to 
bring on speedy vomiting. In cases of this kind, the sulphate of 
zinc will generally answer better than any other article, from the 
promptitude of its operation. It must nevertheless be observed, 
that the very frequent repetition of emetics, more especially anti- 
mony, is apt to bring on much weakness and irritation of the sto- 
mach, which may have a permanent injurious influence on the future 
health of the patient. I have in general preferred the ipecacuanha 
to every other article of this kind. Dr. Fothergill speaks very highly 
of the following combination as an emetic in this affection : 

R. — Pulv. chel. cancror. 3ss. 
Tart, antimon. gr. ii. 
Misce. 

Of this 1, 1$, or 2 grains, may be given at a dose, according to the 
age of the patient. It has been supposed that the union of some 
absorbent with the emetic is peculiarly beneficial in this affection. 



228 WHOOPING-COUGH. 

The syrup of squills also forms an excellent emetic in very young 
patients. I have frequently prescribed this preparation, in union with 
a small portion of antimonial wine, with a very good effect. We 
may also prescribe the antimonal wine in union with an emulsion of 
assafetida, with much advantage as a palliative. 

The narcotics furnish us with several very valuable remedies for 
the treatment of this disease. Of these the belladonna is the most 
celebrated, and unquestionably by far the best article of this kind we 
possess. Professor Borda, who, I believe, was the first who employed 
this remedy in whooping-cough, speaks of its powers with unqualified 
praise. He asserts that, in a number of instances, he has found it to 
remove every vestige of the disease in ten or twelve days; and that 
where it did not remove the disease entirely, it rarely failed to mitigate 
it very considerably. He observes, moreover, that he has known 
cases, which appeared to be beyond the hope of recovery, restored by 
this remedy. The observations of Hufeland and Alibert, not to add 
the testimony of many other writers, speak in terms nearly equally 
favourable, of the virtues of this narcotic in the present disease. A 
large mass of evidence might be adduced from the current medical 
publications, illustrative of the valuable powers of the belladonna in 
this singular malady. From my own experience, I can testify with 
confidence to its virtues as a remedy in this affection. I have within 
the last six years prescribed it in perhaps twenty cases, and in the 
majority of them with manifest advantage.* Since the publication 
of my work on the materia medica, my good opinion of the value of 
this remedy has been considerably increased. In two cases it arrested 
the complaint almost wholly in the course of eight days, although the 
disease was in both instances exceedingly violent. It does not appear, 
however, to answer any useful purpose in cases that are attended with 
fever and bronchial inflammation. In instances of this kind, the lancet 
with blisters, or tartar emetic ointment rubbed on the chest, is the 
means upon which our reliance must be almost entirely placed. In the 
purely spasmodic form of the disease, however, and where all symp- 
toms of inflammation are absent, it is often singularly efficacious.! 

The extract of conium, lactuca viroso, hyoscyamus and opium, have 
also been favourably mentioned as palliatives in this disease. Dr. 
Butler states that he has frequently used the following mixture with 
marked benefit.^ Opium is objectionable, both on account of its 
constipating effect, and its tendency to determine the blood to the 

* The dose should be one drop of the tincture for every year of the child's age, 
three times daily. When the narcotic effect is obtained, cease the remedy, and 
resume when it subsides. 

t [Dr. Jackson, formerly of Northumberland, once published some excellent 
observations upon the influence of belladonna in curing whooping-cough. He 
found the remedy very efficacious in this disease. — Ma] 
% R. — Extract, conii gr. iii. 
Magnes. sulphat. Qi. 
Aq. carui Jv. 
Syrup, rheed. 3L — M. Take thirty drops three times daily. 



WHOOPING-COUGH. 229 

brain. Some writers recommend the tincture of 'cantharides* Dr. 
Sutcliff asserts, that when given to the extent of producing strangury, 
it will sometimes, in a great measure, remove the disease in four or 
five days. This practice has also been pursued with success by Hufe- 
laiid ; and Lettson speaks very favourably of it. Sutcliff used it accord- 
tin to this formula.t M. Fresnoi asserts that he has used the extract 
of the r hus vernix with much success in this disease. He gave half 
a grain, with half an ounce of syrup, every three hours. 

Antispasmodics are frequently prescribed in whooping-cough, and 
sometimes with temporary advantage. An aqueous solution of assa- 
fetida will occasionally palliate the symptoms in cases unattended 
with fever or strong pulmonary irritation. This article answers the 
double purpose of an expectorant and an antispasmodic. I have, in 
a few instances, known material relief obtained from a mixture of the 
vinegar of squills, and an emulsion of assafetida. 

Expectorants also will occasionally mitigate the violence of the 
symptoms. Dr. Pearson strongly recommends the following mix- 
ture, and I have myself known it to give considerable temporary 
relief.^ 

Tonics may, in some instances, be used with much benefit in 
whooping-cough. The Peruvian bark is particularly extolled by Dr. 
Cullen as a remedy in this disease ; but its good effects are in a great 
degree confined to the latter stages of the disease. In some instances, 
the cough assumes a chronic character — continuing long after the 
usual period of its termination; and these cases are frequently con- 
nected with chronic bronchitis. If they are not subdued by efficient 
measures they gradually undermine the constitution, until the system 
is worn down, and the patient dies in a state of marasmus, or under 
symptoms of phthisis pulmonalis. In such cases strong doses of cin- 
chona, or quinine, are often peculiarly serviceable. This tonic may 
also be very beneficially used in cases of a purely spasmodic charac- 
ter, where the disease becomes protracted, and kept up by habit. 

Among the mineral tonics, arsenic has been most commended for 
its powers in this affection. It is, however, wholly inadmissible in 
cases attended with febrile irritation or bronchial inflammation. Dr. 
Ferriar placed much reliance on this remedy in cases free from fever. 
He asserts that, according to his own experience, "arsenic is the only 

* Armstrong, Chambers, Millar, Buchholtz, Loder and others, speak much in 
favour of this remedy in whooping-cough, 
t R. — Tinct. Peruv. spirit. 31. 
Tinct. opii camphor, ^ii. 

Tinct cantharid. 3 ii. Two drachms of this mixture are lobe taken thrice 
daily. 
X R. — Aq. fontanse Ji. 
Syrup. 3iii. 

Subcarbonat. sodae gr. xxv. 
Vin. ipecac, gi. 

Tinct. opii gr. vi. — M. The sixth part, every four or five hours, is the 
proper dose for a child between one and two years old. 



230 WHOOPING-COUGH. 

remedy which promises to shorten the disorder effectually. I have," 
says he, " employed this article in several cases of infirmary patients, 
with tolerable success; and I have occasionally given it in private 
practice with so much advantage, that I think it deserving of further 
trials." I formerly employed this remedy frequently; and in some 
instances its good effects were very obvious. The proper dose for a 
child between one and two years old, is two drops of Fowler's solu- 
tion, twice or thrice daily. I have usually given it in union with 
small doses of the extract of belladonna, or conium. 

The lobelia inflata has proved an excellent remedy in my hands, 
in whooping-cough. Within the last four years, I have prescribed 
this article in a very considerable number of cases, and very gene- 
rally with some advantage, and in several instances with the most 
decided success. It not only often mitigates the violence of the cough, 
but it has appeared to me unequivocally to have shortened the course 
of the disease in several cases. I have usually given the saturated 
tincture in union with the syrup of squills, in doses of ten drops of 
each, four or five times daily, to a child about two years old. To 
several children about this age, I gave as much as twenty drops of the 
tincture of lobelia, and I have always found it strongly palliative 
when it excited sickness or slight vomiting. 

External rubefacient or revulsive applications are particularly valu- 
able in cases attended with bronchial inflammation, or strong and 
dangerous sanguineous congestions in the head. Dr. Gregory advises 
frictions with the following embrocation, along the whole track of the 
spine, and over the chest.* Frictions with tartar emetic ointment 
over the precordial region, will, in many cases, make a powerful 
impression on the disease. This practice originated with Autenreith, 
and has been much employed by the German physicians. Dr. Meyer 
has removed all the symptoms of whooping-cough, in a few days, by 
the application of morphium to the external surface. He applies a 
small epispastic to the epigastric region, and after removing the epi- 
dermis, he applies to the denuded surface half a grain of morphium, 
triturated with a small portion of starch. The application is to be 
renewed every evening. An occasional emetic should also be admi- 
nistered, particularly in infants, in order to free the bronchia? from the 
viscid mucus. t When the disease is complicated with pneumonic 
affections, blisters and rubefacients, in conjunction with venesection, 
and especially leeching on the breast, are indispensable. 

When the disease becomes complicated with chronic bronchitis, in 
the advanced stage of its course, the balsam copaiva is a very valu- 
able remedy. I have, in a few cases of this kind, prescribed this 
article with the most decided benefit; and I know, indeed, no other 

* R. — Antimon. tart. Qii. 

Tinct. cantharid. ,§i. 

Aq. rosar. gii. — M. The tartar emetic is to be dissolved in the rose 
water, and then the tincture of cantharides added to it. 
t Archives Generates. Oct.. 1829. 



ASPHYXIA. 231 

remedy that promises so much as this one, where chronic bronchitis 

attends. 

Various inhalations, also, have been extolled for their good effects 
in this disease. The nitrous acid vapour, and the fumes of tar, have 
been particularly recommended for this purpose. I have employed 
the nitrous acid vapour, in a few cases, with some benefit. 

Dr. Gregory states, that he has derived great advantage from small 
doses of calomel, (a grain twice a day,) with a few grains of scam- 
mony in the latter stages of whooping-cough, attended with symp- 
toms of marasmus. 

Change of air, and exercise by gestation, generally have an excel- 
lent influence in tedious and obstinate cases, attended with much 
exhaustion. In instances of this kind, a change of air, says Dr. 
Gregory, " is often the only thing that gives the patient a chance of 
life." I have seen one very remarkable recovery effected hy remov- 
ing the patient into the country, and the free use of a milk diet. In 
cases attended with bronchial inflammation, this measure is inadmis- 
sible, as it rarely fails to aggravate the symptoms immediately. 

The diet should be light and digestible, and it is particularly im- 
portant to guard the patient against the influence of a cold, variable, 
and damp atmosphere. 

Sect. \\\.— Asphyxia.— Suspended Animation. 

The term asphyxia is here used to designate two varieties of sus- 
pended animation ; namely, those cases which result from the total 
suspension of the function of respiration, by preventing the ingress of 
atmospheric air to the lungs, or by breathing an air incapable of con- 
verting venous into arterial blood ; and those cases of apparent death 
which result from the temporary destruction of the sensibility and 
irritability of the system, by the influence of certain external causes. 

The first variety includes those cases that are produced by hanging, 
drowning, or strangulation, and by the inhalation of carbonic acid ; or 
some other irrespirable gas. The second variety embraces the cases 
that are produced by a stroke of lightning or electricity, and by the 
protracted influence of intense cold.* 

Asphyxia from drowning.— When a person who has been sub- 
mersed in water until all manifestations of life are destroyed, is taken 
out, the face exhibits a turgid and livid appearance ; the eyes are open 
and staring; the limbs somewhat stiff; the tongue usually thrust a 
little beyond the teeth ; and, in most instances, the epigastrium is 
tense and tumid. 

Considerable controversy has existed concerning the mode in which 
drowning causes death. Many have contended that suffocation is 
produced by the water rushing into, and filling up the cavity of the 
lungs. Haller, P. Frank,! Louis and Portal}: mention cases in which 

* Good's Study of Medicine, vol iii, p. 367. 

t System ein. Vollstandiger Med. Polizei, vol. i, p. 186. 

% Instruction sur le Traitement des Asphyxies, 



232 ASPHYXIA. 

the lungs were charged with an abundance of water, sometimes frothy 
and bloody. On the other hand, it has been satisfactorily ascertained, 
that in many instances of death from drowning, very little or no 
water whatever gains admission into the lungs. Tissot,* Goodwin,t 
Kite,} Roesler§, and many other later writers, have published nu- 
merous observations in illustration of this fact ; and it is now, I believe, 
universally admitted, that so long as the larynx retains any degree 
of irritability, no water can enter into the respiratory passages; and, 
consequently, that whenever water is found in the lungs, it must have 
entered into them after life was destroyed. Such is the peculiar sen- 
sibility of the respiratory passages, that the moment water or any 
other substance not in harmonious relation with them conies in con- 
tact with the mucous membrane of the larnyx,the glottis is instantly 
thrown into a state of spasmodic constriction, which wholly prevents 
the ingress of the irritating fluid into the trachea. When the sensibility 
and contractibility of these parts are extinguished, however, the water 
may gain admission into the lungs, and hence it is not uncommon to 
find more or less of this fluid in the air-passages of those who have 
lain a long time under water. 

Some have supposed that drowning destroys life by apoplexy — 
that the functions of the brain are at once destroyed by strong vas- 
cular congestion and extravasation. Portal, || who entertained this 
opinion, states that he found the vessels of the brain, as well as the 
right auricle and ventricle of the heart, jugulars, and descending cava, 
exceedingly turgid with blood in subjects that had died by drowning. 
This opinion is also advocated by Littre, Kite, Walter,1f and JBoer- 
haave. On the contrary, however, many observations have been 
published, which go to show that vascular congestion within the 
head, though an occasional, is by no means a common or general 
phenomenon. Champreax and Faissole assert, that they found no 
marks whatever of unusual sanguineous congestion in the brains of 
persons who had died by submersion.** Schragett and Kuehn Xt state 
that they even found the vessels of the brain atmost entirely empty. 
Fothergill, in a number of experiments made on animals with a view 
of illustrating this subject, fully confirms these observations ;§§ and 

* Avis au Peuple, p. 426. 

t On the Connection of Life with Respiration, &c, p. 14. 

t An Essay on the Recovery from apparent Death. 

$ Diss. Inaug., &c. See Ed. Med. and Surg. Journ., No. lxxxii. Dr. Roesler 
states, that in forty-five experiments he made on animals, he did not in a single 
instance find any thing more than a very small portion of frothy mucus about the 
bifurcation of the trachea. 

II Loc. citat. See also Observ. sur les Effets des Vapeurs Mephitiques. 

Tf De Morbis Peritonei et Apoplexia. 

** Erfahr u. Warneh iiber d. Ursach d. Todes bei Ertruuk. Dantzig, 1772 — as 
quoted by Richter. 

ft Diss, de Submersis, 179. — Richter, Sp. Therap. 

XX Diss, de Causa Mortis Submersorum. — Richter, Sp. Ther. 

H A New Inquiry into the Suspension of Vital Actions, &c. 



ASPHYXIA. 233 

Dr. Currie states that in every instance he examined, he found the 
vessels of the brain entirely free from distension. In nearly all in- 
stances, however, the kings are strongly engorged with blood, and the 
bronchial tubes generally contain more or less of a frothy and bloody 
mucus. 

Bichat has given a very interesting and satisfactory explanation 
of the mode in which death is brought on by submersion, and other 
analogous causes of asphyxia. When respiration is interrupted, the 
blood ceases to undergo the necessary chemical changes in the lungs; 
and black or venous, instead of florid and arterial blood, is imme- 
diately sent to the left side of the heart, and thence throughout the 
system. Now it is well ascertained, that the regular transmission of 
arterial or red blood to the brain, is indispensable to the performance 
of its functions ; and, therefore, one of the first effects of interrupted 
respiration towards the destruction of vitality, is a cessation of cere- 
bral action for want of red or arterial blood to excite the brain. The 
direct and instantaneous consequence of this cessation of cerebral 
action, is cessation of the animal functions, from want of excitement 
in the organs of these functions by the nervous influence and the red 
blood ; and from the same causes the heart soon ceases to act, and the 
circulation stops. Death from asphyxia, by submersion, strangula- 
tion, or the inhalation of mephitic gases, commences therefore in the 
brain, and those vital actions that are immediately dependent on the 
exercise of its functions— namely, sensation, voluntary motion, thought, 
and the mechanical effort of respiration, cease a short time before those 
actions which constitute what are called the organic functions, that is, 
the circulation, absorption, exhalation, &c, are obliterated.* 

Much difference of opinion has been expressed as to the time a 
person may remain under water, in a state of asphyxia, with suffi- 
cient vitality remaining to afford a chance of being resuscitated by 
proper restorative measures. Mr. Brodie thinks it extremely im- 
probable that resuscitation can be effected after the heart has ceased 
to act; and this, he supposes, always occurs within a few minutes 
after the cessation of the respiratory function. Dr. Paris, and other 
late writers, have expressed the same sentiments on this point. Un- 
less, however, we reject no small amount of evidence from sources 
of unquestionable credibility, we are forced to admit that there is in 
some instances a possibility of resuscitation after a much longer period 
of submersion than Mr. Brodie and Dr. Paris are willing to allow. 
The experiments that have been performed on animals in relation to 
this point afford us no satisfactory results. Dr. Davy informs us that 
he has never been able to resuscitate dogs after they had been under 
water two minutes ; and Dr. Colhoun,of this city, states, that in some 
experiments he made oircats, " they invariably died after six minutes 
submersion."! - Dr. Roesler asserts, that he succeeded in resuscitating 
two rabbits, one after 5|, and the other after 9h minutes submersion; 
and a cat after having been submersed llf minutes. He observes, 

* Bichat on Life and Death, p. 136. 

t Gregory's Practice, second American edition, p. 247. 



234 ASPHYXIA. 

however, that he "several times failed when the animals were taken 
out of the water instantly after they seemed to have expired." Ex- 
periments on inferior animals cannot, however, furnish ns with any 
certain data with regard to the human subject. We learn, neverthe- 
less, from these experiments, that very considerable diversity occurs 
as to the time that animals may remain under water and still retain 
sufficient vitality to render resuscitation possible. We see it vary in 
the same species of animals, and in experiments conducted under pre- 
cisely the same circumstances, from a few to ten or eleven minutes; 
and we cannot doubt that a corresponding diversity occurs, in relation 
to this point, in the human subject. Instances of resuscitation after a 
period of submersion varying from fifteen to thirty minutes are on 
record ; and although doubts have been expressed as to the accuracy 
of these statements, we can scarcely, with propriety, permit our scep- 
ticism on this point to carry us so far as to reject, positively, the testi- 
mony upon which they are made. That such instances of recovery 
are, however, extremely rare, is sufficiently evident from the fact that 
the possibility of resuscitation after such protracted periods of submer- 
sion, is now very generally doubted. 

Various circumstances may contribute to hasten or retard the com- 
plete destruction of vitality from drowning. Submersion in very 
cold water will no doubt destroy life sooner than when the water is 
warm or near the temperature of the body ; for in the former case 
the animal temperature will be much more rapidly and completely 
abstracted than in the latter. Previous debility from disease, spasms 
and convulsions, injuries sustained in falling into the water, asthma, 
an apoplectic predisposition, intoxication, torpor from excessive cold, 
an overloaded stomach, &c, may all have a tendency to lessen the 
chance of resuscitation from asphyxia by submersion ; and it is not 
improbable, moreover, that some diversity may exist in different indi- 
viduals as to their respective powers of vital resistance under similar 
circumstances of submersion. 

The morbid appearances observed on dissection in persons who 
have died by drowning or strangulation, are: turgescence of the 
jugulars, venas cavae, right auricle and ventricle of the heart, pulmo- 
nary arteries, and of the pulmonary vessels. The left auricle and 
ventricle are generally empty and flaccid ; and in some instances 
there is considerable vascular congestion of the brain, but very rarely 
so much as to justify the belief that any apoplectic torpor proceeded 
from this cause. In nearly all instances, a considerable portion of 
water is found in the stomach, but the lungs very generally contain 
very little or no water whatever. 

Inquiries have been made to discover some mark by which we 
may decide whether dead bodies found in water have died by drown- 
ing, or whether they have been thrown into the water after they had 
been deprived of life. M. Orfila has paid particular attention to this 
subject, and has examined in detail all the indications that have been 
mentioned as available guides in making up a judgment on this point. 
According to his observations, more or less water always enters into 
the stomach when death occurs by drowning, but never when the 



ASPHYXIA. 235 

dead body is thrown into water. The result, therefore, of his inqui- 
ries on this subject is, that the only certain sign of submersion during 
life, is the presence in the stomach and respiratory passages of water 
similar to that in which the submersion took place ; provided that it 
has not been injected into the stomach after death, and that the water 
in the lungs is found in the ultimate ramifications of the brochia; and 
provided, also, that the body was not found in the vertical position. 
The pressure of a frothy fluid in the air-passages, he says, is only to 
be regarded as a presumptive evidence of submersion during life, and 
this is strengthened by the appearance of an unusual portion of water 
in the pulmonary tissue, since this fluid never penetrates so deeply 
after death as during life by the efforts of respiration. The absence 
of a frothy mucus in the respiratory tubes does not, however, afford 
any proof that death did not occur by submersion.* 

Treatment. — When a person is taken out of water, and it may still 
be deemed proper to make attempts to effect resuscitation, he should 
be immediately well dried, wrapped in blankets, and conveyed to a 
place convenient for the necessary applications. The principal object 
to be aimed at, is a restoration of the action of the lungs, at the same 
time that warmth is gradually communicated to the body. 

With this view, artificial inflation of the lungs has always been 
regarded as the most important resuscitating means we possess in cases 
of this kind. The inflation may be made by blowing the air in the 
mouth through a tube, or by a common bellows, whilst the nostrils 
are held close, to prevent the return of the air by that channel. It is 
to be particularly recollected, however, that very forcible inflation is 
calculated to defeat our purpose, even in cases where the chances of 
resuscitation may be presumed to be considerable. M. Leroy d'Eti- 
olles has recently paid particular attention to this subject, and has 
strongly set forth the injurious consequences of forcible insufflation 
into the lungs in asphyxia. Leroy, Dumeril and Magendie have 
ascertained by repeated experiments, that sheep, foxes, deer, rabbits, 
&c, may be speedily killed by rapid and strong inflation of the lungs, 
even when the insufflation is made with the mouth. When air 
is forcibly thrown into the lungs, it may lacerate the delicate struc- 
ture of the air-cells and cellular texture of the lungs, and thus destroy 
all possibility of restoring the pulmonary functions ; for it appears 
from experiments performed by the same gentleman on dead human 
subjects, that the pulmonary tissue may be readily ruptured by forcible 
inflation.! I n endeavouring to restore the action of the lungs, the air 
should therefore be but moderately forced into the trachea — alternat- 
ing the acts of inflation with compression of the thorax and abdomen, 
so as to imitate the mechanical process of respiration. M. Leroy 
proposes to introduce two fine needles, so as to penetrate the edge of 
the diaphragm, and to pass a gentle current of galvanism through 
this muscle. This has been practised on inferior animals in a state of 

* Revue Medicale, torn, xiii, p. 347. 

t Rapport sur un Memoire de M. Leroy d'EtioUes, relatif a l'lnsufflation du 
Poumon, &c. — Revua Medici!e ; vol. xiii, p. 328. 



236 ASPHYXIA. 

asphyxia, with complete success, after more than five minutes of sub- 
mersion. The galvanic circle must be alternately interrupted and 
closed, so as to imitate the act of respiration. Whenever the circle is 
closed, the diaphragm contracts, and enlarges the thoracic cavity, and 
the air is drawn in on taking off the communicating wires, the dia- 
phragm resumes its former position, and expiration takes place. The 
practice of compressing the chest and abdominal parietes in alterna- 
tion with gentle insufflation is particularly recommended, liy this 
method the blood in the vessels of the abdomen and breast is put in 
motion, and propelled towards the heart and lungs, and the contracti- 
bility of the diaphragm is excited. 

At the same time that the efforts to carry on artificial respiration 
are made, heat should be gradually communicated to the body, by 
wrapping it in dry and warm flannel, and by applying heated cloths, 
or warm bricks wrapped in flannel, or bottles filled with warm water, 
to the lower extremities and body. Care must be taken, however, 
that the warmth be communicated in a gradual manner, for the sud- 
den application of ahigh degree of heat could not fail to do irrepara- 
ble injury, by destroying the small degree of remaining excitability 
of the organization. Frictions with dry flannel or stimulating sub- 
stances, such as powdered mustard or capsicum, will contribute to 
excite the circulation and impart warmth to the body. The injection 
of stimulating fluids into the rectum will be proper, more especially 
when some manifestations of returning life have been established by 
the foregoing measures. For this purpose, a solution of ammonia, 
with wine, or camphor, or warm diluted brandy, may be used ; and 
where the abdomen is tense and tumid, we may inject a warm infu- 
sion of senna, in wine, with the view of exciting the action of the 
bowels. 

Galvanism, also, has been employed as a resuscitating agent in 
cases of this kind. Wiedemann speaks highly of this influence, more 
especially when directed upon the external organs of generation. He 
asserts that he has known the most excellent effects produced by it 
when employed in this manner. It must be observed, however, that 
both electricity and galvanism can be employed with a prospect of 
advantage only when communicated in a very weak state, for when 
strongly applied, they tend to exhaust rather than to increase the vital 
energies. 

Various other modes of exciting the vital powers have been recom- 
mended; such as exposing the eyes to the direct rays of the sun; 
applying volatile and stimulating fluids to the Schneiderian membrane; 
plucking the hairs ; tickling the soles of the feet, sides, and arm-pits ; 
acrid substances applied to the tongue; burying the patient up to the 
head in warm ashes or sand, &c. 

Venesection has been much recommended in asphyxia from sub- 
mersion ; and some have particularly advised opening one of the 
jugulars. Some advantage may, perhaps, be occasionally obtained 
from this measure, where a flow of blood can be procured, by its 
tendency to relieve the oppressive venous congestions of the lungs. 
In general, however, no blood can be obtained by opening a vein, 



ASPHYXIA. 237 

except in cases of very transient submersion, or where the action of 
the heart has been re-excited by the means already mentioned ; and 
here there is much reason to apprehend that injury rather than 
advantage would generally result from this operation. 

The return of the vital actions is at first manifested by transient 
and weak twitches of the muscles of the face, particularly of those 
about the lips; succeeded by feeble, irregular and convulsive efforts 
to breathe ; spasmodic tremor and agitation of the extremities ; a 
small and weak pulse, beating at very long intervals ; and a dis- 
charge of frothy fluid from the mouth. By degrees, sensation and 
the power of motion return ; the lips assume a red hue, the skin 
becomes soft and warm, particularly about the scrobiculus cordis, 
and in some instances vomiting takes place. 

When recovery has been so far effected, the utmost degree of 
caution is necessary to prevent, on the one hand, over-excitation by 
stimulants, and on the other, sinking from deficient support of the 
vital energies by appropriate excitants. I knew an instance where 
a person, after much exertion, was so far resuscitated from a state of 
asphyxia by submersion as to breathe freely, and to manifest con- 
sciousness and the power of voluntary motion. The persons about 
him were directed to give him, from time to time, certain portions 
of warm wine whey. This was wholly neglected, and in four or 
five hours he sunk and expired. Warm wine, or weak brandy 
toddy with warm aromatic ptisans, as infusions of balm, sage or 
catnep, should be given from time to time, according to the state of 
the pulse, and the patient must be kept perfectly at rest in a dry 
and warm bed, with the air freely circulating through the room, if 
the weather be warm. 

Our efforts to effect a resuscitation in cases of this kind, where the 
period of submersion has not been so protracted as to preclude all 
reasonable hopes of ultimate success, should not be too readily aban- 
doned. Instances have occurred in which the signs of returning life 
did not manifest themselves for more than an hour after commencing 
with the resuscitating measures. It has been said, and the observation 
appears to me very correct, that there is much reason to believe that 
some lives are lost in this way for want of duly continued exertions 
to re-establish the vital actions. In still-born infants, I have known 
two instances of ultimate resuscitation, where the signs of returning 
animation were not noticed for above forty minutes after the com- 
mencement of the usual measures. It should also be observed, that 
well-authenticated instances of recovery are on record where the 
resuscitating means were not applied until many hours after the 
person had been taken out of the water ; and hence, where the time 
of submersion has been short, and for want of assistance, means are 
not employed, it may still be proper to make suitable efforts to effect 
a resuscitation, although several hours have elapsed before this can, 
be done. De Ilaen, whose authority cannot be questioned, asserts 
that he resuscitated a person seventeen hours after he had been taken 
out of the water ; and other similar instances might be adduced, 



238 ASPHYXIA. 

which, though less remarkable, perhaps, are equally encouraging to 
late attempts of this kind. 

2. Asphyxia from the inhalation of irrcspirable gases.— The 
most common cause of this variety of asphyxia is the inhalation of 
carbonic acid gas. When this aeriform poison is undiluted with 
atmospheric air, it will destroy life almost instantaneously, by abo- 
lishing, at once, all the sensibility and irritability of the nervous sys- 
tem. When mixed with a portion of atmospheric air, its sedative 
effects on the brain are less vehement and sudden ; giving rise to 
vertigo, faintings, insensibility, asphyxia, or death, according to the 
degree of its purity and the length of time during which persons arc 
exposed to its influence. When life is suddenly destroyed by inhal- 
ing this gas in an undiluted state, the dead body is pale, collapsed, 
and flaccid. In instances, however, where death or asphyxia is 
caused by a gradual destruction of the vital powers, from the gas 
being more or less mixed with atmospheric air, the face exhibits a 
tumid and livid appearance, the veins about the neck and head are 
turgid, the tongue somewhat swollen, the lips blue, with suggilations 
on different parts of the surface, and the body remains warm for 
many hours, or even for several days. On dissection, the sinuses of 
the brain, the jugulars, right side of the heart, pulmonary arteries, 
the lungs, and the cavac, are always strongly congested with black 
and generally fluid blood. The pulmonary veins, left side of the 
heart and aorta, on the contrary, are empty, or contain but a small 
quantity of blood. The ventricles of the vein are commonly charged 
with a considerable portion of bloody serum, and the cellular struc- 
ture about the head and neck is often found infiltrated with the same 
kind of fluid. The bronchia are filled with a frothy mucus more or 
less tinged with blood ; and the mucous membrane of the stomach 
and intestines usually exhibits a dark red, ecchymosed, and distended 
appearance. The epiglottis is generally erect, and the glottis pa- 
tulous.* 

Carbonic acid gas produces its fatal effects on the animal economy 
both by excluding the requisite portion of oxygen or respirable air 
from the lungs, and thereby preventing the conversion of venous 
into arterial blood, and by a peculiar and exceedingly powerful 
sedative principle independent of its mere irrespirable character. 
Animals die much more speedily when confined in this and other 
mephitic gases, than when placed in an exhausted receiver, or when 
the atmospheric air is otherwise excluded from the lungs ;t and frogs, 
worms, leeches, and snails, are killed in a few hours by being placed 
in carbonic acid gas, although capable of living a long time when 
simply deprived of atmospheric air. J These facts show conclusively 
that in addition to the mere exclusion of respirable air, there is also 

* Portal. Observations sur les Effets des Vapeurs Mephitiques. 
t Fothergill. A New Inquiry into the Suspension of Vital Action in cases ol 
Drowning and Suffocation. 

t Carminati. De Animalium ex mephitibus. et noxiis halitibus interim ejue- 
que Causae, p. 89. 



ASPHYXIA. 239 

a deleterious impression made on the vital powers by inhaling this 
gaseous poison ; and it acts, therefore, at once like submersion or 
strangulation, and as a powerful sedative poison. 

There are several other gaseous substances, which, when inhaled 
in a concentrated form, produce immediate asphyxia or death. The 
fumes of sulphur, sulphuretted hydrogenous gas, nitrous gas, azote, 
hydrogene, and certain gaseous poisons, generated by putrefying 
animal and vegetable substances, destroy life with more or less ra- 
pidity. Of these gases, azote, and pure hydrogen, appear to destroy 
life simply by their not being respirable, or by preventing the che- 
mical changes of the blood in the lungs, in the same manner that 
submersion or obstruction of the trachea produces this effect.* 

Treatment. — When the asphyxia from this cause (carbonic acid 
gas) is incomplete, with some degree of sensibility remaining, the 
patient may be generally soon recovered by conveying him imme- 
diately into the open air, supporting him in a sitting posture, dash- 
ing a little cold water upon his face and breast, applying dry fric- 
tions to the extremities, and, as soon as he can swallow, giving him 
small portions of cold wine and water. 

If the unfortunate individual is in a state of perfect asphyxia, 
without any manifestations whatever of life, we may sometimes 
succeed in effecting resuscitation by the following course of manage- 
ment. He should be speedily carried into a free and cool air, divested 
of his clothes, and laid upon a sheet spread on the floor, or the ground, 
with his head and shoulders somewhat raised. Cold water must 
now be dashed upon his breast, and cloths dipped in cold water ap- 
plied to the head ; or he may be supported in a sitting posture, and 
the water poured on the head. In some cases, the moment the cold 
affusion is made, a convulsive respiratory effort is excited. In an 
instance to which I was called about a year ago, I found the patient 
without the slightest indications of vitality. Having stripped off his 
clothes, I dashed a bucket full of cold water over the head and breast, 
and almost at the same moment, I observed a short convulsive gasp. 
By continuing the affusions at short intervals, the respiratory efforts 
were repeated, at first very weak, and at intervals of nearly a minute, 
and by the additional aid of stimulating frictions, the respiration was 
fully established in about an hour after the first symptoms of return- 
ing life. 

Frictions with the flesh-brush, or with stimulating embrocations, 
are important auxiliaries in re-exciting animation in cases of this 
kind. We may also derive advantage from volatile stimulating 
applications to the mucous membrane of the nose, by means of a 
feather — such as aqua ammonia, ether, and camphorated spirits. 
At the same time, also, stimulating enemata should be used, parti- 
cularly a solution of the carbonate of ammonia in a mucilaginous 
fluid. Richter speaks favourably of the injection of cold water and 
vinegar for this purpose. If the act of respiration be not soon ex- 
cited by the cold affusions, artificial inflation of the lungs must be 

* Bichat on Life and Death, p. 242. 



240 ASPHYXIA. 

resorted to, in the way mentioned above. Upon these two means 
we must chiefly rely in our efforts to effect resuscitation. When the 
respiration is partially established, but continues very laborious, and 
with a rattling noise in the bronchia, considerable benefit will some- 
times result from the abstraction of from eight to ten ounces of blood 
from the arm. As soon as the respiration is fully established, the 
patient should be wiped dry, and laid in a comfortable bed, and small 
portions of warm wine, or wine-whey, or some other gentle stimu- 
lating beverage allowed. 

Galvanism has been employed, and, in some instances, with mani- 
fest advantage, in asphyxia from mephitic gases. The galvanic 
current should be weak, and passed along the course of the pneumo- 
gastric nerves, by placing the negative conjunctive wire in contact 
with the scrobiculus cordis, and the positive pole with the part im- 
mediately over the par vagum in the neck, just below the stemo- 
mastoid muscle. 

After the vital actions have been re-established, the arterial ex- 
citement, in some instances, becomes violent and tumultuous. The 
heart palpitates vehemently ; the pulse is full, strong, and hard ; the 
vessels of the head turgid, and a disposition to heavy sleep ensues. 
Under these circumstances, venesection is indispensable, and the 
blood should be suffered to flow until the activity of the circulation 
is considerably moderated. In general, much caution is necessary 
after resuscitation is effected, neither to excite the vital powers too 
much — which may readily be done — nor to suffer them to languish 
for want of some gentle stimulus. 

3. Jlsphyxiafrom electricity. — When electricity is passed through 
the animal system, in currents of moderate intensity, it excites and 
invigorates the vital energies ; but when its intensity is great, it sud- 
denly suspends, or entirely destroys the sensibility and irritability of 
the nervous system, and gives rise to more or less complete asphyxia, 
or immediate and irrecoverable loss of vitality. 

The appearances exhibited by persons who have been struck by 
lightning, vary considerably. In most instances, red streaks may 
be noticed on the breasts and arms, of an ecchymosed and highly 
irritated appearance, and generally of a zigzag form. The hair is 
usually singed on some parts; and small blisters, like those produced 
by a scald, occur on different parts of the body. Sometimes blood 
is discharged from the ears, and suggilations of large extent are fre- 
quently found on the trunk and extremities. Internally, structural 
lesions are but rarely detected in persons who are killed by lightning. 
In general, the heart is turgid with blood, but the lungs are usually 
collapsed, and entirely free from vascular congestion. The blood is 
always deprived of its coagulability by a fatal stroke of electricity; 
and the body commonly enters into putrefactive decomposition with 
extraordinary rapidity. When the electric stroke does not entirely 
destroy the vital powers, the face is generally red and bloated ; more 
or less blood often issues from the mouth and nose ; respiration is 
slow and very laborious; the pulse is extremely weak and irregular, 
or entirely absent; and spasmodic twitches of the muscles of the eye- 



ASPHYXIA. 241 

lids, mouth, and throat, sometimes occur. Persons who are recov- 
ered from a state of asphyxia caused by lightning, generally suffer 
for a long time afterwards with tremors, painful sensation, swellings, 
and some degree of numbness in the extremities, more especially in 
the legs. Such individuals usually retain a particular susceptibility 
to the electric influence, and are apt to feel a peculiarly uneasy feeling 
on the approach of a thunder storm. 

The treatment of asphyxia from this causo, does not differ from 
that which is mentioned for asphyxia from mephitic gases. Cold 
affusions are particularly valuable to re-excite the latent vital ener- 
gies in cases of this kind. Cold water should be copiously and 
frequently dashed over the whole body, and frictions diligently made 
with the flesh-brush or pieces of rough flannel. Galvanism and 
electricity also have been especially recommended in asphyxia from 
a stroke of lightning. Stoll asserts, that animals in a state of as- 
phyxia from an electric shock, have been speedily recovered by a 
second shock of this power;* and Bernt assures us that in a case 
produced by a stroke of lightning, a second shock affected a resus- 
citation, t M. Abilgaard also has related some instances of asphyxia 
from this cause, in inferior animals, in which resuscitation was effect- 
ed by a second shock of electricity 4 

4. Asphyxia from cold. — When the body is subjected to the 
influence of intense cold, the superficial blood-vessels shrink ; the 
surface becomes pale and contracted ; respiration oppressed ; the 
extremities benumbed and weak; and finally, an irresistible desire 
to sleep comes on ; and, unless speedy aid be obtained, insensibility, 
asphyxia, and death, inevitably ensue. For the mode in which 
these effects are produced by low temperature, the reader is referred 
to the article Cold, page 44, of the first volume of this work. 

Instances of resuscitation from asphyxia, caused by intense cold, 
are by no means uncommon ; and cases are related in which reani- 
mation was effected many hours, or even several days, after the 
asphyxia was produced. § The principal resuscitating means in cases 
of this kind is the gradual communication of warmth to the body. 
The introduction of warmth requires, however, the utmost degree 
of caution ; for, if the heat be rapidly communicated, it will inevi- 
tably destroy the remaining vitality, or should a partial recovery 
ensue, fatal gangrene would be the certain consequence. When a 
person is found in a state of insensibility from cold, he must on no 
account be immediately conveyed into a warm chamber, or placed 
near the fire. His body should be immersed in spring water, or 
water fresh drawn from a well. Burying the body in fresh snow 
has also been recommended for this purpose. Richter states, that 
the snow-bath is decidedly the most important resuscitating means 

* Rettungsmittel in plotz. unfallen., p. 63. 

t Vorlesungen iiber. d. Rettungsmittel beim Scheintode, p. 121; as quoted by 
Richter, Spec. Therap., vol. viii, p. 647. 
X Loc. Med. Havnien. Collectan., &c., t. ii. — Good. 
\ Kruinilz. Oekonom. Encyclopaedia, Th. XT, p. 261. Richter. Sp. Ther. 
VOL. II. — 17 



242 PNEUMOTHORAX. 

we possess in cases of this kind. After the body has been suffered 
to lie in water or snow for forty or fifty minutes, it should be care- 
fully dried with soft pieces of flannel, wrapped in blankets, and con- 
veyed into an unheated chamber. Gentle frictions with flannel 
should now be resorted to, and if no manifestations of respiration 
occur, artificial inflation of the lungs should be practised. If these 
efforts succeed in restoring symptoms of life, the temperature of the 
room should be very gradually increased, and bottles filled with 
lukewarm water laid" to the feet, and about the body. When the 
power of deglutition is restored, moderately warm ptisans— such as 
balm, sage, or elder-blossom tea, and diluted warm wine, may be 
given with advantage ; but the stronger stimulants must be rigidly 
interdicted. 



Sect. IV. — Pneumothorax. 

The collection of aeriform fluids in the cavity of the pleura, is 
termed pneumothorax. This is no very uncommon occurrence, 
and is always attended with the most distressing effects on the action 
of the lungs and heart. In most cases the confined air is fetid, re- 
sembling the smell of sulphuretted hydrogen. This is always the 
case when the passage formed between the cavity of the pleura and 
the air-cells is the result of a gangrenous eschar of the surface of the 
lungs, and where more or less purulent matter is effused into the 
cavity of the chest. When such a communication is effected by 
ulceration, tuberculous softening, or otherwise, the air is forced into 
the cavity of the pleura during the acts of respiration, and as its 
return into the lungs must always be very slow, and often wholly 
impossible from the valvular form of the opening, it accumulates 
with more or less rapidity, until the lungs are so greatly compressed 
as to render respiration extremely difficult, and finally to arrest it 
entirely. The lung of the affected side becomes, at last, compressed 
into a very small and nearly solid mass ; and when the disease occurs 
in the left cavity, the heart and mediastinum are usually forced com- 
pletely into the right side of the chest. The affected side of the 
chest becomes manifestly bulged out, and the intercostal spaces 
wider and more raised or puffy than natural. The abdomen, also, 
usually becomes more prominent in consequence of the depression 
of the diaphragm against the abdominal viscera by the distending 
force of the confined air. 

Patients affected with pneumothorax experience great pectoral 
oppression and difficulty of breathing, attended generally, with more 
or less palpitation of the heart, and often with severe pain under the 
sternum or the affected side of the chest. They are usually obliged 
to remain in a sitting posture, and can never rest even for a moment 
recumbent on the sound side. M. Rayer has related a case in which 
the patient was forced to remain day and night resting on his knees 
and elbows in bed. When the pneumothorax occurs in the left side 
of the chest, the palpitation of the heart is usually felt in the right 



PNEUMOTHORAX. 243 

side only; but this can take place only in very violent cases, where 
the confined air is so abundant as to force the heart completely into 
the right cavity of the thorax. 

The diagnosis of this affection is not attended with difficulty 
except to those who are not experienced in mediate auscultation and 
percussion. By these diagnostic means, the practised ear may arrive 
at certain conclusions as to the existence of air in the cavity of the 
chest. " Whenever we find one side of the chest sounding more 
distinctly than the other, and at the same time perceive the respira- 
tory murmur distinctly in the least sonorous side, and not at all in 
the other, we may be assured that there exists pneumothorax in the 
latter side of the chest." Even when, on percussion, we find both 
sides equally sonorous, the existence of this affection may be inferred, 
if auscultation do not enable us to perceive the respiration on one 
side whilst it is audible on the other. When the disease supervenes 
on pleuritic effusion into the cavity of the pleura, the affected side 
will yield a dull sound when percussion is made, before the pneumo- 
thorax commences. " As soon, however, as the air begins to accu- 
mulate, the resonance of the chest returns in some degree, in the situ- 
ation occupied by the air, without, however, being as distinct as in 
the sound side. Day after day, the extent and intensity of this reson- 
ance increase ivithout any return of the sound of respiration: 
and if there had previously been any remains of the respiratory 
murmur, even this now totally vanishes." But when the lung of 
the affected side is attached to the costal pleura by means of a very 
short cellular tissue, the diagnosis, even by auscultation and percus- 
sion, is rendered more uncertain ; for at the point of adhesion the 
respiration will still be audible. (Laennec.) When, on examining 
the chest with the stethoscope, that peculiar metallic sound is heard, 
which Laennec calls metallic tinkling, and which has been compared 
to the sound of a drop of water falling into a bottle half full, it indi- 
cates the existence both of air and a puriform matter in the cavity of 
the pleura, with a fistulous opening between the cavity of the chest 
and the bronchia. This metallic sound, says Laennec, "exists only 
in that variety of pneumothorax which is complicated with empyema ; 
and may be considered as a pathognomonic sign of this combination 
in conjunction with a fistulous opening into the bronchia." The 
metallic tin/cling of pneumothorax may be distinguished from that 
which occurs from a large tuberculous excavation in the lungs partly 
filled with a purulent fluid, by the greater weakness of the sound, 
and the narrow space to which it is confined in cases of this latter 
kind. 

There is some risk in mistaking emphysema for pneumothorax in 
examining by percussion and auscultation; particularly by those who 
are not accustomed to this mode of exploration. M. Laennec points 
out the following difference in the results obtained by the employ- 
ment of these diagnostic means in these two affections. " In pneumo- 
thorax, the respiratory murmur is wholly absent, except at the point 
between the scapula and spine, corresponding to the roots of the 
lungs. In emphysema, the respiratory sound is never completely 



244 PNEUMOTHORAX. 

inaudible, and there is a slight rattle which never occurs in the 
former complaint. Pneumothorax comes on rapidly, and cannot 
continue long without giving rise to dangerous symptoms, or even 
proving fatal; emphysema, on the contrary, comes on slowly, and 
is never so severe as to confine the patient to bed, or incapacitate 
him for his ordinary occupation." 

Post-mortem appearances. — On cutting into the cavity of the 
pleura, the air usually rushes out with very considerable force. In 
many cases there is a small portion of sero-purulent fluid found in 
the chest; and in nearly all instances, the surface of the pleura is 
more or less extensively covered with a thin layer of pseudo-mem- 
branous matter. Not unfrequently, slight adhesions occur between 
the costal and pulmonary pleura of the affected side. The lung of 
the side affected is usually compressed into a small, irregular, and 
compact mass ; and if the disease is in the left cavity, the heart and 
mediastinum are pushed completely within the right cavity of the 
thorax. Frequently a fistulous opening may be detected between 
the cavity of the pleura and the bronchia. 

Causes. — Pneumothorax frequently occurs in consequence of tuber- 
culous excavation near the surface of the lungs, and the formation of 
a fistulous opening into the bronchia. Chronic pleuritis, also, may 
give rise to tins affection. Some of the cases related by M. Itard, 
originated from chronic pleurisy. When the disease arises from 
chronic inflammation of the pleura, it is always preceded by the 
effusion of sero-purulent matter into the cavity of the chest, and in 
such cases no opening into the bronchia usually occurs. It would 
appear that in cases of this kind, the air within the cavity of the 
pleura " is the product of a chemical decomposition of the effused 
albuminous and puriform fluid. In proportion as the gas is thus 
developed, the effused fluid becomes absorbed, until the disease has 
acquired the character of complete pneumothorax. The rupture of 
a vomica, giving rise to a communication between the bronchia and 
the cavity of the pleura, appears to be no uncommon cause of this 
affection. When the disease occurs in this way, the air in the thorax 
is generally associated with a purulent fluid. Pneumothorax may 
also arise from the extrication of fetid gas, by the decomposition of a 
gangrenous eschar dissolved and discharged into the cavity of the 
chest. (Laennec.) 

Treatment. — This is always an extremely dangerous affection; 
for although the mere accumulation of air in the cavity of the pleura 
may not of itself be so formidable, yet the organic lesions with which 
it is almost invariably connected, are generally of such a nature as 
to admit of but slender hopes of cure, or even of a considerable pro- 
longation of life. It would seem, nevertheless, that spontaneous 
cures of this affection have taken place. Such a favourable termina- 
tion is, however, an extremely rare occurrence, and is supposed to 
take place in the following manner. The lung being strongly com- 
pressed by the air that rushes into the cavity of the pleura, through 
the aperture made into the bronchia, gradually collapses, if no adhe- 
sions exist, until it remains quiescent. In this state of collapse and 



PNEUMOTHORAX. 245 

rest, the lung is in the most favourable condition for the healing of the 
opening through which the air passed. "If the opening heals, the 
air will be absorbed, and the patient gradually recover." 

The general remedial management must, of course, be modified 
according to the nature of the lesion or primary affection, upon which 
the pneumothorax depends. When there is reason for believing that 
the air compressing the lungs is the result of chronic inflammation of 
the pleura, some advantage may be expected from counter-irritating 
applications to the chest : — Such as blistering, pustulation with tartar 
emetic ointment, cupping, moxa, issues, setons, &c. Some benefit 
may also result from gentle courses of mercury, and from the internal 
exhibition of diuretic remedies. In cases manifestly connected with 
tuberculous softening, and fistulous opening into the bronchia, little 
or no advantage can be looked for from any remedies of this kind. 

Different opinions have been expressed as to the propriety of punc- 
turing the thorax for the purpose of giving exit to the confined air in 
this affection. Laennec speaks favourably of this operation, although 
it does not appear that he has himself resorted to it with success in 
any case of this kind. The only instance in which he performed this 
operation, terminated fatally in a few hours after the puncture was 
made. The opening was made between the fifth and sixth ribs, and 
very little air, and no purulent matter escaped from the incision. 
This appears to have been a case of empyema conjoined with pneu- 
mothorax, for when after the death of the patient, an incision was 
made about the middle of the fourth intercostal space, a considerable 
quantity of pus was discharged; and on making an opening into the 
chest near the junction of the third rib with its cartilage, much fetid 
gas rushed out. This case cannot, therefore, be regarded as a fair 
test of the value of this operation in pneumothorax. Riolan states 
that he has seen several instances of the successful operation of para- 
centesis on patients who were supposed to labour under dropsy, with- 
out anything having been evacuated from the chest but air. (Laennec.) 
These, doubtless, were cases of simple pneumothorax, and may be 
regarded as encouraging examples of the usefulness of this operation 
in the present affection, when uncombined with empyema. 

"Pneumothorax," says Laennec, "complicated with liquid effu- 
sion, and still more, with pulmonary fistula, is a case of a most serious 
nature, and leaves little hopes of a cure being effected. This, how- 
ever, must not be regarded as quite impossible even in the severest 
cases. I formerly proved the possibility of the cicatrization of tuber- 
culous excavations; and the observations of Bacqua, Jaymes, and 
Robin, (Joiwn. Ghi. de Med., 1813,) to which I could add a more 
recent case of the same kind, sufficiently prove, that even in such 
cases, we may attempt this last resource with some prospect of suc- 
cess." That the operation in question is a proper one, in perhaps 
every variety of pneumothorax, can scarcely be doubted ; for even 
where the prospects of an ultimate cure cannot be entertained, we 
may at least reasonably expect to prolong the patient's life by giving 
exit to the confined air, and thereby preventing suffocation from the 
compression of the lungs. The object of the operation is to prevent 



246 PNEUMOTHORAX. 

the fatal compression of the lungs, by the confined gas, and to place 
this organ in a state of quiescence, so favourable to the healing of 
the aperture through which the air passes from the bronchia into the 
cavity of the pleura. Although the propriety of this operation seems 
to be obvious in this affection, yet we find but very few instances 
recorded of its having been performed in pneumothorax. There is 
a highly interesting case reported in the Medico- Chirugical Review, 
(January, 1829,) in which the chest was punctured ; but although 
great relief was the immediate consequence of the evacuation of the 
air, the patient in a few days sunk under the disease.* 

A case of pneumothorax is related by Dr. Davy, in which this 
operation was performed with entire success. The patient was af- 
fected with haemoptysis, which came on after " a severe fall on the 
left side of the chest, received eighteen months previously." While 
under treatment for this affection in the Military Hospital at Chat- 
ham, he was one morning seized with a violent fit of coughing, and 
symptoms of pneumothorax immediately succeeded. 

The thorax was punctured with a trochar between the eighth and 
ninth ribs, "the integuments and intercostal muscles having been 
previously divided with a scalpel." As but little air escaped by this 
opening, it was " concluded that its escape had been prevented by 
adhesions of the pleura at the point were the puncture was made ;" 
and on the following day the operation was repeated just below the 
left papilla. From this orifice a large quantity of air rushed out "as 
if from a blow-pipe." The relief obtained was immediate and great, 
and the patient continued to improve regularly. This and the pre- 
ceding case, says Dr. Johnson, are the only instances in which this 
operation was performed for pneumothorax in England. 

* The patient was a member of our profession, and was visited during his ill- 
ness by the majority of the most eminent physicians and surgeons of London. 
The incision was made between the sixth and seventh ribs, anteriorly. When 
the pleura was punctured, " a rush of air instandy issued forth with a loud hissing 
noise, and strong enough to extinguish several candles. The relief was almost 
instantaneous. The patient turned on his back, and breathed with comparative 
freedom. ;; On the fourth day after the operation, the patient was found to be sink- 
ing, and, after a strong paroxysm of convulsions, expired on the afternoon of this 
day 7 . On dissection, an aperture was discovered at the division or cleft between 
the two lobes. This aperture was circular, about the size of a crow-quill, and 
evidently fistulous. It communicated with a small tuberculous excavation. The 
right lung was much more tuberculous than the left; but the tubercles were in a 
quiescent state. Med. Chir. Rev., Jan. ; 1829. p. 482. 



DISEASES OF THE HEART. 247 



CHAPTER V. 

CHRONIC DISEASES OF THE HEART. 

Sect. I. — Of the Diseases of the Heart. 

There is scarcely a subject in pathology that has attracted so much 
attention of late years, as the chronic affections of the heart. The 
researches of Corvisart,* Kreysig,t Testa,J Laennec,§ Burns,|| and 
Abererombie,1T have thrown great light on this important class of dis- 
eases, and it is from these sources chiefly that the following observa- 
tions are drawn.** 

Symptoms. — The general symptoms are nearly the same in every 
variety of structural disease of the heart. More or less habitual 
dyspnoea almost universally attends in affections of this kind ; and a 
careful attention to the particular modifications of this symptom, is 
of great importance in a diagnostic point of view (Corvisart). The 
acts of inspiration are either very quick, and effected more by the 
action of the ribs than by the diaphragm, and somewhat wheezing; 
or the patient breathes as if he had been walking rapidly, and appears 
to make unusual efforts in filling the lungs ; or finally, the respiration 
is calm, and without any particular effort, but the air does not appear 
to enter into the lower portion of the lungs. Mental agitation, or corpo- 
real exertions, particularly walking, or ascending acclivities or stairs, 
never fail to bring on more or less violent paroxysms of dyspnoea ; 
and in the latter stages of the disease, the most trifling excitements of 
this kind give rise to extremely distressing spells of suffocative breath- 
ing, attended with great weight and constriction in the breast, inex- 
pressible anxiety, a turgid and usually livid hue of the face, particu- 
larly of the lips, which are swollen and purple ; distension of the 
veins in the neck and head, and an expression of extreme distress and 
suffering in the countenance. These paroxysms of dyspnoea often 

* Essai sur les Maladies et les Lesions Organiques du Coeur. 

t Die Krankheiten des Herzens. Berlin, 1814-17. 

X Delle Malattie del Cuore. 

$ Treatise on the Diseases of the Chest; translated by J. Forbes, M. D. : 3d 
edition. 

II Observations on some of the most frequent Diseases of the Heart. By Allan 
Burns, 1809. 

IT Contributions to the pathology of the heart. Transact. Med. Chirurg. Society 
ofEdinb., vol. i, 1824. 

** [The late Dr. Hope, of London, published at a later date an excellent work 
on this subject. — Mc] 



248 DISEASES OF THE HEART. 

last but a few minutes, and rarely continue beyond half an hour, and 
subside rapidly to the ordinary state of respiration. During the early 
period of the disease, or in cases of a less serious character, the patient 
is able to lie down, (though rarely with any degree of ease on (he 
right side,) but the sleep is much disturbed by alarming dreams, fre- 
quent startings, and spells of palpitation— obliging the patient sud- 
denly to sit up in bed. In violent or inveterate cases, however, the 
patient is sometimes obliged to remain day and night in a sitting or 
half-sitting posture — every attempt to lie down being immediately 
followed by the most harassing paroxysm of palpitation of the heart 
and suffocative breathing. One of the most frequent symptoms 
of cardiac diseases is irregular action of the heart. Sometimes the 
heart beats tumultuously and indistinctly, which has been compared 
to the bubbling of boiling water; and at others it seems to be in a 
state of tremulous agitation. More commonly, however, it beats 
vehemently against the side of the thorax, so as to enable a person 
distinctly to hear its throbs, and to communicate a motion to the 
whole superior part of the body. Syncope, too, is no uncommon 
occurrence in diseases of this kind. The patient is liable to occasional 
attacks of partial fainting, often of long continuance, during which 
he experiences a feeling of great oppression and constriction in the 
region of the heart, a partial loss of consciousness and sensorial power, 
inexpressible anxiety in the praecordia, with an extremely feeble and 
fluttering or intermitting pulse, and scarcely any perceptible respira- 
tion. From this state of adynamia, he sometimes passes suddenly 
into deep syncope, approaching the character of asphyxia, and after 
a short period, again suddenly recovers his entire consciousness.* 
In some cases, paroxysms of angina pectoris occasionally super- 
vene; and instances occur in which the cardiac disease gives rise to 
convulsions and apoplexy.t The habitual aspect of the countenance, 
during the intervals of the exacerbations of the dyspnoea, is usually 
pale and cachectic, with a leaden lividity of the prolabia, and puffy 
swelling under the eye. (Edema of the feet and legs is usually one 
of the earliest symptoms of organic affections of the heart. In the 
progress of the disease, oedema gradually extends higher, and often 
invades the scrotum, labia, and even the trunk. In some instances, 
the pulse differs but very little from its natural state, except during 
the occasional paroxysms of the dyspnoea and palpitation ; but more 
frequently it is irregular, intermitting, and often has a peculiar jarring 
beat, or is sharp, exceedingly firm, and incompressible. Organic 
diseases of the heart are very generally attended with a peculiarly 
irritable temper, and a disposition to melancholy and hypochondria- 
sis.:]: Symptoms of indigestion, too, are very apt to occur in diseases 
of this kind ; and in many instances there exists a strong tendency to 
hemorrhage, particularly from the lungs and the nose. Patients 

* Kreysig, loc. cit., b. i, p. 332. 

t Dr. Forbes. Edition of Laennec on the Diseases of the Chest 

X Testa ; loc. c it. 



DISEASES OF THE HEART. 249 

labouring under cardiac affections are liable to sudden and severe 
pains in different parts of the body. 

Dr. Adams has given the history of a very remarkable case, in 
which no pulse was to be felt in any artery of the body for six 
weeks ; neither were the movements of the heart perceptible by the 
hand applied to the chest ; but an obscure, undulating motion could 
be heard by applying the ear to the region of the heart. On dis- 
section, the heart was found large and flabby ; the semilunar valves 
of the aorta were completely ossified ; and the coronary arteries 
« were so completely converted into bone as to be quite solid, hav- 
ing no perceptible cavity except at the distance of an inch from their 
origin."* 

Dissection shows that cardiac diseases have a particular tendency 
to produce great engorgement of the capillary vessels, and it is to 
this circumstance, no doubt, that we have to ascribe the dropsical 
effusions into the cellular structure of the cavity of the chest, so 
common in these affections. In almost all those who die of organic 
disease of the heart, the mucous membrane of the alimentary canal 
exhibits a deep red, or violet colour, and, in most instances, " the 
liver and capillaries situated beneath the serous, mucous, and cuta- 
neous tissues, are strongly gorged with blood. t A very vivid red- 
ness of the internal surface of the heart and large vessels is also 
a very common phenomenon in subjects who have died of such 
affections, and this is particularly noticed where the affection con- 
sists in a morbid dilatation of the ventricles of the heart. 

Causes. — The etiology of the diseases of the heart is enveloped 
in much obscurity. There exists, no doubt, a natural predisposition 
in some individuals to affections of this kind ; but our notions con- 
cerning the nature of this predisposition amount only to some 
plausible conjectures. An inordinate irritability of the heart and 
arteries has been mentioned as a circumstance predisposing to car- 
diac affections ; and an original defect in the muscular energies of 
the heart, as well as a disproportion between the activity of this 
organ and the blood-vessels, may also, occasionally, be the foundation 
of such diseases. It is said, that the predisposition to organic affec- 
tions of the heart is in some instances manifestly hereditary, and 
its occasional prevalence in certain families renders this opinion very 
probable. Dr. Forbes refers to Lancisi, Albertini, Morgagni, Portal, 
Corvisart, and Testa, for striking examples of this kind; and a re- 
markable instance is related in the eleventh volume of the Medical 
Commentaries. A strumous habit is considered by Testa as a 
strong predisposing cause of organic affections of the heart ; and 
Dr. Forbes says, that his own experience has led him to the same 
conclusion. " In this case," he observes, " I have thought that the 
disease is developed at a more early period than under other cir- 
cumstances. Perhaps in this case an original disproportion of the 

* Cases of Diseases of the Heart, &c. By Robert Adams, M. B., &c. &c. 
Dublin Hospital Reports, 
t Laennec, loc. cit., p. 592. 



250 DISEASES OF THE HEART. 

parts usually exists." The remote causes of the diseases of the 
heart appear to be numerous, and very diverse in their characters. 
The following have been mentioned as the most common and 
powerful. 

1. Moral Causes.— Corvisart, Kreysig, and others, assert that 
mental emotions are among the most frequent and powerful causes 
of structural diseases of the heart ; and from the well-known influ- 
ence of violent affections of the mind on this organ, there can be 
no doubt, indeed, of their tendency, when frequently repeated, or of 
protracted duration, to give rise to such diseases. Dr. Forbes states, 
that he attended a poor woman " affected with organic disease of 
the heart, of many months' standing, which was suddenly produced 
by horror at seeing her infant scalded to death."* Instances have 
occurred, in which sudden terror, anger, or excessive joy, has deter- 
mined the blood so vehemently to the heart as to cause immediate 
rupture of its ventricles.! 

2. Gout and rheumatism. — Organic diseases of the heart are 
probably more frequently occasioned by metastasis of gout or rheu- 
matism, than by any other cause. Sauvages mentions instances of 
cardiac affections, alternating with paroxysms of gout;J and Dr. 
Scudainore has related a remarkable case of palpitation of the heart 
of three years standing, which suddenly disappeared on the super- 
vention of an attack of articular gout.§ Rheumatism, however, 
appears to be still more frequently concerned in the production of 
cardiac affections. Dr. Cox has adduced some interesting examples 
of the dependence of the diseases of the heart on metastasis of rheu- 
matism. Numerous cases of organic diseases of the heart and peri- 
cardium, which he met with during his connection with Guy's Hos- 
pital, were referable to, or connected with rheumatism.|| Dr. Cox 
states, moreover, that his observations have led him to believe, 
that " the majority of cases of organic diseases of the heart in young 
people," are connected with rheumatism. Dr. James Johnson also 
observes, that " long and attentive observation" has convinced him, 
" that a very considerable proportion of those active enlargements or 
hypertrophic of the heart which are now so frequently met with in 
practice, are dependent on rheumatism." Dr. David Dundas,1f and 
Dr. Hawkins** also, have published observations illustrative of the 
rheumatic origin of organic cardiac diseases ; and Dr. Forbes has 
related several interesting instances of this kind.tt 

* Laennec on the Diseases of the Chest, third edition. 

t Richter, Specielle Therapie, b. v, p. 129. 

t Nosologia Method., torn, i, p. 518. 

$ A Treatise on Gout and Rheumatism, fourth edition, p. 44. 

II Observations on Acute Rheumatism and its Metastasis to the Heart, by Thos. 
Cox, M. D., Lond., 1824. 

<ft Med. Chir. Transact., vol. i. 

** Rheumatism and some Diseases of the Heart. Lond. ; 1826. 

ft Original Cases, &c., p. 1 12, and p. 165. See also a note at p. 597 of his Trans- 
lation of Laennec on the Chestj fourth edition. 



DISEASES OF THE HEART. 251 

3. Cutaneous diseases. — The repulsion of chronic cutaneous erup- 
tions may give rise to organic diseases of the heart. Kreysig says, 
that when cardiac affections arise from causes of this kind, the disease 
is apt to occur in the external or internal membranes of the heart ; 
and according to the observations of Testa, the most common struc- 
tural lesions resulting from repelled cutaneous affections,, are thicken- 
ing and induration of the pericardium. Osiander mentions ulcerations 
of the external surface of the heart and of the pericardium ;* and 
Mekel has related a similar instance of disorganization of these parts, 
apparently the consequence of repelled cutaneous eruptions. Cardiac 
affections have also been known to result from the suppression of 
habitual perspiration of the feet, and from the healing up of old ulcers 
and issues. (Richter.) 

4. Syphilis is also mentioned as no uncommon cause of diseases of 
the heart. Corvisart was of opinion that the excrescences which are 
sometimes found on the valves, usually depend on a syphilitic taint, 
and Lieutaud particularly refers to this disease as a cause of various 
structural disorders of the heart. t Mr. Bertin, however, thinks, that 
the influence of this cause, in relation to cardiac diseases, has been 
much overrated ; an opinion which he was led to adopt after an 
experience of twenty years in the venereal hospital. Laennec also 
rejects the opinion of Corvisart with regard to the syphilitic origin of 
the excrescences on the valves. 

5. Diseases of other organs, particularly such as are attended with 
long-continued and severe dyspnoea, are especially apt to give rise to 
hypertrophy or dilatation of the heart, through the constant efforts 
this organ is called on to perform, in order to propel the blood into 
the lungs, against the resistance opposed to it by the cause of the 
dyspnoea." Chronic pulmonary catarrh, phthisis pulmonalis, chronic 
peripneumony, empyema, and emphysema of the lungs, frequently 
give rise to these cardiac affections, and almost necessarily, where 
there exists a congenital disproportion between the size of the heart 
and the diameter of the aorta. (Laennec.) Chronic diseases seated 
in the abdomen, are also mentioned among the occasional causes of 
organic affections of the heart. Testa thinks, that induration and 
enlargement of the liver may give rise to diseases of this kind, but 
Corvisart, more correctly I think, regards the hepatic affection as the 
consequence, rather than the cause, of disease of the heart. " More 
probably," says Forbes, " it may be merely a concomitant, and the 
consequence of those chronic disorders of the stomach and upper 
bowels which are too frequent in all classes of people to be safely 
admitted as either a common cause or effect of affections of the heart." 
It is supposed that visceral enlargements within the abdomen tend to 
produce cardiac diseases by compressing the large vessels, and by 
impeding the circulation through the affected viscus, in consequence 
of which greater efforts of the heart are made to oppose these causes 
of obstruction. 

* Denkwiirtigkeiten, &c, Th. i, p. 146, as quoted by Richter. 
t Hist. Anatom. Med., torn. ii ; ob. 510-516. — Sprengle. 



252 DISEASES OF THE HEART. 

6. Scurvy has also been supposed to be capable of giving rise to 
structural disease of the heart, more especially to a morbid softness 
and flabby state of its structure. 

7. Congenital disproportion of the different parts of the heart, and 
particularly between the left ventricle and the aorta, is no doubt at 
the bottom of the majority of the instances of hypertrophy and morbid 
dilatation. Where such a condition of the central organs of the cir- 
culation exists, everything which is capable of causing a long-con- 
tinued preternatural momentum of the circulation, or an impediment 
to the free passage of the blood through the lungs, or sudden and 
forcible determinations to, and congestions of the heart and large 
vessels may readily give rise to aneurismal dilatation of this organ. 
Playing wind instruments, carrying heavy burdens, or straining in 
lifting heavy weights, running, the inhalation of suffocating vapours, 
protracted rigors of intermitting and other febrile diseases, intoxica- 
tion, mental emotions, lymphatic and other tumours pressing on the 
carotids or some other arterial trunk, and a great variety of other 
causes of a like tendency, will be apt to produce structural disease of 
the heart in individuals thus predisposed by a congenital conforma- 
tion of this organ. 

Blows, falls, and external injuries of the chest, may likewise give 
rise to organic cardiac diseases. Inflammation of the heart, too, is 
frequently concerned in the development of affections of this organ. 
Indurations, morbid softening, excrescences, pseudo-membranous for- 
mations, adhesions, effusions into the pericardium, ulcerations, &c, 
may be regarded as the immediate consequences of cardiac inflam- 
mation, in whatever way this latter condition may be produced. 

Diagnosis. — The diagnosis of the diseases of the heart is attended 
with much difficulty. The symptoms of organic affections of this 
organ are particularly liable to be confounded with simple hydrotho- 
rax, hydro-pericardium, neuralgic angina pectoris, and even with 
asthma. Laennec asserts that none of the symptoms mentioned above 
can at all be regarded as pathognomonic, or sufficient to indicate dis- 
ease of the heart, " since they are common to many other affections, 
and particularly to almost every chronic disease of the lungs." There 
is much truth in this observation ; but I apprehend, nevertheless, 
that the uncertainty of the diagnosis, founded merely on the symp- 
toms, is not in general so great as might appear from the sentiments 
expressed by Laennec. When we find a patient complain of more 
or less habitual dyspnoea, greatly aggravated on corporeal exertion; 
slight oedema of the feet; a puffy and anxious appearance of the 
countenance, with a livid hue of the prolabia ; frequent palpitations 
or tumultuous action of the heart ; an inexpressible feeling of anxiety 
in the region of the heart during the paroxysms of dyspnoea; the 
occasional sudden occurrence of elastic puffy swelling of the lower 
eyelids and the upper lip ; an irascible and gloomy temper ; quick 
and short inspirations; a deep purple and bloated aspect of the face 
during the paroxysms of dyspnoea ; with an absence of the peculiar 
wheezing and rattling noise in the lungs ; and a free secretion of urine; 
when these symptoms are noticed, we have strong reasons for pre- 



DISEASES OF THE HEART. 253 

snming that there exists some disease of the heart. The sudden and 
exceedingly distressing effects that arise from bodily exertions in dis- 
eases of the heart, are often sufficiently characteristic to distinguish 
them from simple hydrothorax. Every muscular effort, or unusual 
exercise, aggravates to an extreme degree the dyspnoea and dis- 
tressing anxiety and agitation in organic cardiac diseases. Going up 
stairs or walking up a rising ground almost immediately excites the 
most alarming and suffocative paroxysms of dyspnoea. Although 
these causes also aggravate, in some degree, the difficulty of breath- 
ing in simple hydrothorax, yet these consequences are by no means 
so violent and agitating in this disease as in the affections of the heart. 
Without doubt, however, mediate auscultation affords the most cer- 
tain means for recognizing the presence of organic cardiac diseases ; 
but the tact for profiting by this diagnostic test can only be acquired 
after a long course of careful experience, and it must, moreover, be 
observed, that even in the most experienced hands, the stethoscope 
more frequently gives fallacious indications with regard to the affec- 
tions of the heart, " than in any of the other diseases which it is cal- 
culated to discover." (Laennec.) 

Prognosis. — In general, the prognosis in diseases of the heart is 
particularly unfavourable. Nevertheless, much relief may sometimes 
be procured even in cases of great severity. We " sometimes," says 
Laennec, " see the judicious combination of blood-letting, diuretics, 
and tonics, remove the impending suffocation, the palpitation, and the 
dropsy, and restore the patient frequently for a long period to a tole- 
rable degree of health : and it is commonly only after a great many 
attacks recurring after considerable intervals, that the disease at length 
proves fatal." 

Death almost always occurs very suddenly, and not unfrequently 
when the patient seems to be free from any unusual disturbance from 
the disease. Indeed the mere degree of severity of the symptoms is 
often very fallacious inja prognostic point of view. In some instances, 
much continued uneasiness, with frequent exacerbations of distressing 
violence, will continue for many years before the disease terminates 
in death. In other cases, with less structural disorder of the heart, 
and no very severe symptoms, the disease will unexpectedly terminate 
fatally in a short period after the first manifestations of its presence. 
Dilatation and attenuation of the parietes of the ventricles; hypertrophy 
with softness of the muscular structure ; and contraction or diminution 
of the openings of the heart, appear to be most apt to prove suddenly 
and unexpectedly fatal. The occurrence of other diseases in persons 
labouring under organic affections of the heart, always enhances 
the liability to a speedy unfortunate termination very considerably. 
Pregnancy, parturition, intermitting fever, &c, are especially calculated 
to increase the sufferings and dangers of structural cardiac affections. 
In some instances, diseases of this kind give rise to a protracted state 
of asphyxia, and cases of spontaneous resuscitation have occurred after 
the patient had been supposed to be dead. 

Forms of structural cardiac disease. — A great variety of organic 
affections of the heart, and its immediate appendages, are mentioned 



254 DISEASES OF THE HEART. 

in the works on this subject. The following are the principal forms 
of these diseases: 1. Thickening and enlargement of the heart, or 
hypertrophy; 2. Attenuation of the parietes of the ventricles; 3. 
A morbid softness and flabby state of the structure of the heart; 4. 
Dilatation of its cavities; 5. Aneurysmal pouches of its ventricles; 6. 
Ossifications of the valves, and other parts; 7. Excrescences of a warty 
character on the valves, and from the internal surface of the ventricles; 
8. Contraction of the openings of the heart; 9. Absence of laceration, 
or ulcerative destruction of the valves; 10. Adhesions between the 
pericardium and the heart ; 11. Tumours on the heart, pericardium, 
or aorta ; and 12. Polypous excrescences. Of these affections, the 
severest and most common are : dilatation of the ventricles ; hyper- 
trophy, or enlargement and thickening of the parietes, or the connec- 
tion of both these conditions. The following observations on these 
affections are drawn from M. Laennec's work on the diseases of the 
chest. 



1. Hypertrophy of the Heart. 

The term hypertrophy is employed to designate an unnatural 
thickening or increase of the muscular structure of the heart, with- 
out a proportionate dilatation, though frequently with considerable 
diminution of its cavities. (Laennec.) In general this thickening is 
at the same time attended with an increased firmness of the structure 
of the heart; but it is also sometimes found connected with a mor- 
bid softening of its substance, though the latter condition appears to 
be the consequence of a distinct disease, as it frequently exists inde- 
pendently of hypertrophy. In some cases, the hypertrophy is con- 
fined to a single ventricle ; sometimes both ventricles are affected, 
with or without a similar condition of the auricles ; and occasionally, 
though very rarely, the auricles alone are found in a state of hyper- 
trophy.* M. Laennec states that he has seen the walls of the left 
ventricle more than an inch thick, and even as much as eighteen 
lines at the base. The thickening generally "diminishes gradually 
from the base to the apex. The columnae carna3 of the ventricles, 
and the pillars of the valves, acquire a proportionate enlargement, 
and the septum between the two ventricles becomes also considera- 
bly thickened in the disease of the left ventricle." In many instances 
the cavity of the ventricles is diminished in size. Laennec has 
found the left ventricle so small in hypertrophy as " scarcely to be 
capable of containing an almond with its shell." 

The symptoms of hypertrophy of the left ventricle are: A 
strong and full pulse ; violent beating of the heart against the chest: 
and a violet or red tint of the face. The patient almost constantly 
feels the action of the heart ; though very violent and tumultuous 
palpitations are less apt to occur in this than in some other affections 
of the heart. These symptoms, though frequently present, are not 
invariably so ; for in some very severe cases, the pulse is small and 

* Laennec. 



DISEASES OF THE HEART. 255 

weak. The signs furnished by immediate auscultation, however in 
connection with the state of the pulse, and the appearance of the 
countenance, will in general enable us to recognize the presence of 
this affection. Between the fifth and sixtli cartilages of the ribs the 
heart "gives a very strong impulse, and is accompanied bv a duller 
sound than natural, and prolonged in proportion as the thickening 
is more considerable. The contraction of the auricle is very short 
productive of little sound, and consequently scarcely perceptible in 
extreme cases. The sound of the pulsation of the heart is confined 
to a small extent, being in general scarcely perceptible under the left 
clavicle, or at the top of the sternum ; sometimes it is confined to the 
point between the cartilages of the fifth and seventh ribs ; and the 
impulse of the heart is rarely perceived beyond the same limits 
except during palpitation." 

Laennec, Berlin, Richerand, and others, consider simple hyper- 
trophy of the left ventricle as peculiarly apt to produce apoplexy: 
but Dr. Kelly has very ingeniously, though certainly not satisfac- 
torily, controverted this opinion. 

When the right ventricle is in a state of hypertrophy, there is 
more dyspnoea and the countenance is of a deeper hue, and in nearly 
all instances the external jugular veins are turgid, and have a mani- 
fest pulsating action communicated to them by the regurgitation of 
the blood. Laennec states that he has never found this "symptom 
absent in hypertrophy of the right ventricle. The stethoscope gives 
the same results as when the left side is affected, with the exception 
that the heart is felt beating with most force at the bottom of the 
sternum, instead of the space between the cartilages of the fifth and 
sixth ribs. Laennec asserts, that the place where the action of the 
heart is most distinctly felt, may be regarded as a certain diagnostic 
in relation to this subject. When the hypertrophy exists in both 
ventricles, "the signs consist in a reunion of those that belong to 
hypertrophy of each side ; but those of the right side are almost 
always more marked." 

2. Dilatation of the Ventricles. 

This constitutes the passive aneurism of the heart of Corvisart— 
the ventricles being preternaturally dilated, their parietes attenuated 
and the muscular structure, in many instances, so soft that it may be 
readily broken down by mere pressure between the fingers. The 
walls of the left ventricle have been found so thin as to measure 
scarcely two lines at the thickest part, and not more than half a line 
at the apex ; « while the right ventricle is sometimes so completely 
extenuated as to appear merely composed of a little fat and its in- 
vesting membrane." Though sometimes confined to one ventricle 
dilatation usually affects both at the same time. This condition of 
the heart is very commonly accompanied by other organic affections 
of this organ— particularly ossification of the valves, and congenital 
narrowness of the openings into the aorta or pulmonary artery; and 
Benin thinks that the morbid dilatation is always caused by 'these 



256 DISEASES OF THE HEART. 

and other circumstances capable of impeding the free course of the 
blood as it is thrown out by the ventricles. This appears to be the 
most common of all the organic cardiac diseases, and seems gene- 
rally to be produced in a very gradual manner. 

In dilatation of the ventricles, the pulse is usually soft and weak, 
and the palpitations of the heart feeble and indistinct. Mr. Forbes 
thinks that pain, or a peculiar feeling of distress in the region of the 
heart, extending sometimes to the top of the sternum, between the 
shoulders and the left arm, as in angina pectoris, deserve notice as 
signs of dilatation of the heart. He refers also to headache, an affec- 
tion which he thinks " he can trace in a great number of cases to 
this condition of the heart as its exciting cause." When the left 
ventricle alone is thus affected, the contractions of the heart will be 
heard very distinctly with a clear and sonorous sound between the 
cartilages of the fifth and seventh ribs, through the medium of the 
stethoscope ; and " the degree of distinctness of the sound, and its 
extent over the chest, are the measure of the dilatation. Tims when 
the sound of the contraction of the ventricles is as clear as that of 
the contraction of the auricle, and if it is, at the same time, percepti- 
ble on the right side of the back, the dilatation is extreme." (Laen- 
nec.) When the right ventricle is in a state of morbid dilatation, 
the pulse and action of the heart "are nearly the same as in dilata- 
tion of the left ventricle." In general the jugulars are distended; 
the oppression in the chest is apt to be great ; anasarcous effusions 
occur; the countenance is usually livid, and bloody expectoration 
is very common. Laennec states that an habitually turgid state of 
the jugulars, unattended with a pulsatory motion, is the most con- 
stant and characteristic " of the equivocal signs of this affection." 
The only constant and truly pathognomonic sign is the loud sound 
of the heart, perceived under the lower part of the sternum, and 
between the cartilages of the fifth and seventh ribs of the right side. 
The palpitations which accompany this affection consist principally 
in an increase of the frequency and sound of the contractions, while 
at the same time, the impulse of the heart's action is frequently 
feebler than in the ordinary state of the patient. Laennec places 
but little reliance on percussion, as a means of forming a diagnosis 
in cases of this kind. In general, percussion at the bottom of the 
sternum elicits a dull sound. 

Dilatation with hypertrophy of the ventricles, is much more 
common than either of these affections separately, and may exist in 
one or both ventricles. The contractions of the ventricles in this 
affection may be very distinctly felt by the hand; "and if we atten- 
tively observe the patient, we frequently perceive the head, limbs, 
and even the bed-clothes, strongly shaken at each systole of the heart. 
If we press on the region of the heart, this organ seems to be irri- 
tated by the pressure, and beats more forcibly still." The pulse is 
full, hard, strong, frequent and vibrating; the pulsations of the super- 
ficial arteries are often visible. Percussion on the region of the heart 
almost always elicits a dull and obscure sound. With the stetho- 
scope, the pulsations of the heart are heard distinctly over a great 



DISEASES OF THE HEART. 257 

extent — they may be perceived below the clavicles, on the sides, and a 
little to the left side of the spine. In some instances, when the heart 
palpitates strongly, besides the impulse of the heart, which seems 
communicated by a large surface, we can distinguish another shock 
which is sharper, clearer, and shorter, although occurring at the 
same time, and which seems to strike the walls of the chest with 
much smaller surface. This blow seems evidently occasioned by the 
apex of the heart. 

3. Jlnevrism of the Jlortci. 

Aneurismal dilatations of the aorta are very common. In some 
instances the dilatation exists without rupture of any of the arterial 
coats, constituting what authors call true aneurism; in others, the 
internal coat is ruptured, forming the kind of arterial dilatation de- 
nominated false aneurism. Sometimes a large extent of the aorta 
is in a state of morbid dilatation ; but much more commonly the 
dilatation is confined to the ascending portion and arch. These 
aneurismal tumours often acquire a very large size. Laennec has 
seen them " as large as the head of a full grown foetus." By com- 
pressing the heart and lungs, these tumours are apt to give rise to 
very alarming and distressing affections. When the coats of the 
artery are much diseased, or the dilatation becomes very great, the 
tumour sometimes bursts and causes immediate death. In some 
cases the "aneurism compresses the trachea, or one of the two bron- 
chial tubes ; flattens and eventually destroys a part of them, and 
death ensues from the rupture of the tumour." The oesophagus 
may also be thus compressed, but this occurs but seldom. The heart 
is usually pushed to one side or downwards. Sometimes the aneu- 
rism bursts into the air-cells of the lungs ; but rupture into the left 
cavity of the pleura is by far the most common. Aneurismal tumours 
of the aorta often destroy the vertebral column to a great depth, by 
causing gradual absorption, without leaving any other marks of dis- 
ease, such as caries, &c. When this takes place, the tumour becomes 
entirely destroyed on the side next the vertebrae — the naked bone 
forming the posterior wall of the sac. The sternum is also in some 
cases destroyed, when the aneurism is in the ascending aorta. When 
the arch of the aorta or the arteria innominata is the seat of the 
aneurism, the tumour often projects at the top of the sternum, or 
under the cartilages of the first false ribs of the right side. It is not 
always the largest aneurisms that most readily make their way ex- 
ternally. Sometimes those of the size of an egg produce this effect, 
whilst occasionally, those of the size of the head of a full grown 
foetus remain quite covered, and even compressed by the sternum. 
(Laennec.) 

Diagnosis. — The signs of aneurism of the aorta, according to Cor- 

visart, are: inequality of the pulse in both arms; obscure sound on 

percussion; a rattling noise in the throat, "and dragging downwards 

of the larynx when the tumour presses upon the trachea; and a 

vol. n. — 18 



258 DISEASES OF THE HEART. 

whizzing or rushing at the top of the sternum perceptible by the 
hand." Laennec, however, places no reliance on these signs, and 
observes that aneurism of the aorta has no symptoms peculiar to it 
—the symptoms just noticed "being indicative merely ot the change 
or compression of the adjoining organs." It, however, we find under 
the sternum or below the right clavicle, the impulse of the circulatory 
organ isochronous with the pulse, and perceptibly greater than that 
of the ventricles examined in the region of the heart, we have reason 
to suspect dilatation of the ascending aorta or arch— the more so as 
it is extremely rare to feel the impulse of the organ of the circulation 
beyond the region of the heart, even in cases of the most marked 
hypertrophy. If this phenomenon is found constant after repeated 
examinations, we may consider the diagnosis as certain. Examined 
with the stethoscope, the aneurismal tumour usually elicits a peculiar 
purring thrill, and bellows-like sound. In general, however, aneu- 
rism of the aorta can only be recognized with certainty when it shows 
itself externally ; but even when it passes through the walls of the 
chest, " it is not always distinguishable from other tumours. The 
origin and progress of this affection are indeed sometimes so obscure 
as scarcely to give any reason for suspecting its existence ;" and the 
first indication of its presence is often the death of the individual as 
instantaneously as if by a pistol-bullet. 

Treatment of the Organic Diseases of the Heart. 

The greater number of organic diseases of the heart must be re- 
garded as absolutely incurable. This, however, does not apply to 
hypertrophy and dilatation, whether existing singly or concomitantly 
with each other; for by a judicious and energetic course of treatment, 
both these cardiac affections may occasionally be entirely removed, 
and almost invariably greatly mitigated. M. Laennec observes, that 
« the greater number of practitioners are too much in the habit of de- 
spairing of success in cases of this kind, and therefore content them- 
selves with attacking such urgent symptoms as may arise in its 
progress ; and yet I believe, there is no one who has not succeeded 
every now and then even by this symptomatizing treatment, in pro- 
longing for fifteen or twenty years the lives of individuals affected with 
organic diseases of the heart." Organic affections of the heart are 
indeed much more generally regarded as mere subjects of patholo- 
gical speculation than as diseases, in some instances at least suscep- 
tible of cure or melioration by proper remedial management. "We 
think such an estimate," says Dr. Johnson, "not only a false one, but 
pernicious in its consequences both to the patient and practitioner." 

The general and paramount indication in the treatment of organic 
cardiac affections — more especially of hypertrophy and morbid dila- 
tation, is to reduce and keep down uninterruptedly the momentum 
of the circulation; and this is to be fulfilled by lessening the mass 
of the blood by venesection, and a reduction in the quantity and nutri- 
tient qualities of the food, and by carefully avoiding every thing 
which has a tendency to increase the action of the heart and arteries. 



DISEASES OF THE HEART. 259 

When there is reason to believe that there exists hypertrophy, the 
volume oi' the circulating fluid should be at once decisively dimi- 
nished by as large a blood-letting " as the patient can bear without 
fainting;" and this is to be repeated at intervals of three or four 
days, until the " palpitations have ceased, and the heart yields up a 
moderate impulse under the stethoscope." In cases where there is 
simple dilatation, without an increased thickness of the muscular 
structures of the ventricles, the abstractions of blood can scarcely be 
carried to a very great extent, or at least be very frequently repeated, 
without the risk of great prostration, or fatal syncope. In cases of 
this kind, it will nevertheless be highly proper to keep down the mass 
of the blood ; but after one or two effectual bleedings this may be 
most prudently done by an extremely abstemious mode of living. 

A reduction of the ordinary quantity of food is indispensable to 
full success in cases of this kind. The good effects of blood-letting 
will be but temporary, and in general wholly inadequate, unless the 
rapid generation of new blood be at the same time obviated, by put- 
ting the patient on a very spare and diminished allowance of diet. 
Laennec advises that the food should be diminished to one half at least 
of the ordinary quantity taken by the patient; and it should consist of 
mild and unirritating articles of diet, at the same time that the mass 
of the blood is kept down by repeated bleedings. All kinds of stimu- 
lating liquids must be rigidly forbidden. This course of depletion 
and tow diet must be steadfastly pursued, the patient at the same 
time avoiding, as much as possible, every thing which may cause 
inordinate excitement of the circulatory system, particularly exercise, 
strong mental emotions, and stimulating ingestion. " When the patient 
has been two months without experiencing palpitations, and without 
increased impulse of the heart, we may lessen the frequency of the 
bleedings, and diminish in some degree the severity of the regimen, 
if the patient is not at all habituated to, or satisfied with his allow- 
ance. But we must return to the same means, and with the same 
rigour, if the augmented impulse of the heart should return." (Laen- 
nec.) This method of treating organic affections of the heart was 
first practised by Valsalva and Alberiine.* In addition, however, to 
the foregoing measures, they kept their patients in bed during a period 
of forty days, and directed the frequent use of laxative enemata. 
Dr. Forbes states that he has resorted to this method of treatment 
with much temporary advantage, and he cites the names of Lancici, 
Guattini, Sabatier, Pelletan, Corvisart, Hodgson, Bertin, and others, 
in favour of its usefulness in organic cardiac affections. Morgagni 
also speaks of this reducing plan of treatment in affections of this 
kind with decided approbation ;t and there can be no doubt, indeed, 
of its direct tendency to lessen the violence of the symptoms, or to 
effect a cure in hypertrophy of the heart. Laennec observes, that 
even where the disease has advanced so far as to have induced great 

* Morgagni. De Sedibvts et Causis Morbor., &c. Epistol. xvii ; art. 3. 
t Loc. citat. Epistol. xviii, art. 30. 



260 DISEASES OF THE HEART. 

dyspnoea, anasarca, and a general cachectic state of the system, "we 
must nevertheless fearlessly prosecute the plan of starvation and 
bleeding." 

When the symptoms just mentioned, namely, habitual dyspnoea 
and dropsical effusions occur, diuretics will generally assist materi- 
ally in alleviating the sufferings of the patient. Dropsical effusions 
into the cavity of the pleura or pericardium almost invariably occur 
in the progress of organic affections of the. heart, and it would appear 
that the immediate cause of death in many instances are effusions of 
this kind, impeding the actions of the lungs and heart. Diuretics 
can therefore rarely be dispensed with in affections of this kind, and 
they are in fact often decidedly palliative. We may frequently suc- 
ceed in removing the dropsical effusions from the chest, by the judi- 
cious employment of this class of remedies, so as to procure much 
temporary relief. The effusion, it is true, will generally soon return 
again, but I have known the life of an individual protracted for four 
or five years, by occasionally effecting a removal of the dropsical ac- 
cumulation. I attended an old lady some years ago who laboured 
under symptoms of hydrothorax ; by low diet and the use of the 
squill and nitre, in doses of about two grains of the former to fifteen 
of the latter, I succeeded in removing the water from her chest, three 
times in the course of about fifteen months. She finally died sud- 
denly, and on dissection, the heart was not only in a state of remark- 
able hypertrophy, but the mitral valves were completely ossified. 
Some writers have strongly recommended digitalis as a diuretic in 
organic cardiac affections, attended with dropsical effusions ; and 
from the known powers of this article to curb the action of the heart, 
it would seem to be peculiarly applicable in cases of this kind. Laen- 
nec, nevertheless, does not speak very favourably of its powers in 
the class of diseases now under consideration. He observes, that 
he has never found it to control the action of the heart, " even when 
the dose was carried to the extent of producing vomiting and vertigo." 
Its diuretic powers are equally uncertain, but of its occasional sedative, 
as well as diuretic influence, no doubt can be entertained, and as 
both these effects are peculiarly desirable in cases of this kind, it un- 
questionably deserves a fair trial, where we find other articles ineffi- 
cient. I have known the infusion of the erigeron heterophyllum to 
produce very active diuresis, and of course advantage, in one instance 
of cardiac disease accompanied by hydrothorax. 

Purgatives may also be resorted to with advantage, where the 
dropsical accumulations become considerable in cardiac affections; 
and they are more especially necessary where diuretics fail to pro- 
cure relief. One of the best medicines for this purpose is the follow- 
ing combination, which rarely fails to procure copious watery dis- 
charges from the bowels, and at the same time free diuresis.* 

* R. — Tart, potass, ^iss. 
Sulph. potass, ^ss. 
Pulv. scillae 3H. 
Tart, antimonii gr. ii.— M. S. Take a teaspoonful four or five times daily. 



DISEASES OF THE HEART. 261 

When the cardiac affection consists in simple dilatation, the pulse, 
as has already been stated, is generally feeble and compressible, and 
the depletory measures must therefore be employed with caution. 
But even in cases of this kind we must endeavour to obviate a ple- 
thoric state of the vessels, by an occasional small blood-letting and 
an abstemious diet. The principal remedies here are the ferru- 
ginous preparations and the vegetable bitters. These may be bene- 
ficially given in union with some of the milder aromatic substances, 
particularly the infusions of valerian, cat-mint, and of orange flowers. 
(Laennec) To curb the action of the heart, digitalis is particularly 
useful in instances of this kind. From one-fourth to half a grain of 
the powder of this vegetable may be given every two hours until 
the frequency of the pulse is moderated, and it should be repeated 
afterwards in such a way as to keep up a slight sedative impression 
on the circulatory system. Cases of mere dilatation, however, are 
seldom permanently benefited by remedial treatment ; and the pros- 
pect of effecting an entire cure is always exceedingly small. By the 
employment of chalybeate waters, or some of the officinal prepara- 
tions of iron, and weak infusions of the tonic vegetable bitters, and a 
simple and abstemious course of living, with a careful avoidance of 
all unusual corporeal exertions and spirituous potations, a considera- 
ble degree of comfort may be obtained by patients affected in this 
manner.* 

Baron Larrey, in his recent work,t has related some cases, from 
which it would appear that counter-irritation by means of moxa 
is capable of doing much good in dilatation and enlargement of the 
heart. He insists upon it, in opposition to Corvisart and others, 
that hypertrophy cannot be removed by the most rigorous system 
of depletion. He assures us, however, that during a period of more 
than thirty years, he has had frequent opportunities of witnessing 
the beneficial effects of counter-irritation. Adopting the opinion lhat 
in organic affections of the heart, the remote cause almost always 
consists in "some morbific principle, whether syphilitic, scrofulous, 
herpetic, or otherwise," he lays down two indications to be pursued 
in the treatment of these cardiac affections, namely, to counteract 
or destroy the primary specific cause, by specific remedies ; and draw 
off the irritation from the heart, by establishing an external counter- 

* [By a long perseverance in the general course of treatment described by our 
author, I have witnessed apparent cures of several cases of hypertrophia of the heart. 
Certainly I have succeeded in the cure of three cases of aneurism of the ascending 
aorta even after the tumours had begun to protrude externally through the carti- 
lages of the ribs, on the right side, in two cases, and at the top of the chest, through 
the sternum and right clavicle, in the other. The blood gradually became co- 
agulated within the sacs in all these cases and finally confined the current of circu- 
lation within its natural channel. The solid tumour which resulted was by degrees 
reabsorbed in each of these cases, and the patients lived for years afterwards en- 
gaged in active employments. — Ma] 

t Clinique Chirurgicale. 



262 DISEASES OF THE HEART. 

irritation by means of moxa. Against the supposed specific cause 
he employs mercurial remedies, and lie avers that these are always 
highly beneficial when combined with counter-irritation. In active 
hypertrophy he uses local depletion over the cardiac region, after 
which he applies the moxas. He speaks also very favourably of 
cold in the form of ice applied to the region of the heart. The moxas 
are to be applied first to the track of the intercostal nerves behind 
the left hypochondrium, and then gradually brought round and for- 
wards to the anterior cardiac region. His favourite formula for 
administering the mercurial remedies is the following: 

R. — Muriat. hydrarg. corros. 
Muriat. ammon. 
G. opii, aa gr. v. 
Aq. distil] at. Ibi. 

Misce ft. solutio. Of this, a dessertspoonful is to be taken several times, 
we presume, daily, for he does not state the frequency of the dose. 

"One great principle," says Dr. Forbes, "is always to be kept in 
view, in the treatment of diseases of the heart, namely, the removal 
of all disorders in other organs which can act as a source of irritation 
to the heart." It is particularly important to attend to the gastric 
and hepatic functions: and hence we find that patients almost always 
experience some relief when these functions are brought into a 
healthy condition. " I would lay it down," says the writer just 
quoted, " as a general rule in chronic affections of the heart, that 
previously to having recourse to any remedies intended to act di- 
rectly on it, we ought to he assured that the digestive organs are in 
a healthy state— -that their mucous surfaces are free from irritation — 
their vascular system not morbidly distended, and that the liver is 
performing the secretory functions freely and regularly. When de- 
rangements of this kind are present — a few leeches to the prsecordia 
or anus, some small doses of oxyde of mercury and castor oil, a mild 
and spare diet, and bodily and mental repose, will often do more to 
tranquilize the circulation than more active and rougher means. 
Jind, indeed, in many cases, more especially in the earlier stages, 
ivhen the stethoscope gives but little information, it is not until 
we have restored the organs to a comparatively healthy condition, 
that we can know how' far the disordered action of the heart de- 
pends on sympathy with these, or is the consequence of incipient 
organic lesion of the heart."* Concomitantly with the employ- 
ment of the above-mentioned tonics, very considerable advantage 
may in general be derived from an occasional dose of three or four 
grains of blue pill at night, and a mild laxative in the morning; and 
to keep up the regular action of the skin, the tepid shower-bath will 
generally be useful. 

* Laennec on the Chest, by Dr. Forbes. 



DISEASES OF THE HEART. 



263 



Sympathetic Affections of the Heart. 

Symptoms differing in no material circumstance from those which 
have already been mentioned as belonging to organic affections of 
the heart, are not unfrequently the result purely of a sympathetic 
irritation of this organ without any structural lesion whatever. I 
do not now allude to those cases of angina pectoris which arise 
from metastastic or sympathetic irritation, and which are probably 
always of a strictly neuralgic character. The heart is liable to be 
excited into vehement and tumultuous action, by a variety of causes 
not immediately connected with lesion or disorder of its structure ; 
and the most alarming instances of this kind often result from an 
irritation located in some remote part of the system. It is of much 
consequence, in a practical point of view, to keep this, indeed, well- 
known fact in mind, in prescribing for cardiac affections. I have, m 
several instances, been consulted by persons subject to extremely 
violent paroxysms of palpitation, who were supposed to be labour- 
ing under chronic affection of the heart, and who were completely 
relieved by a course of treatment calculated to restore the healthy 
condition of the digestive functions and of the liver. When we find 
paroxysms of palpitation come on while the patient is quiet, perhaps 
lyino- down, without pain in the region of the heart, at the same time 
that°there are symptoms of indigestion, particularly eructations of 
flatus there can be but little doubt that the cardiac affection is symp- 
tomatic of gastric irritation. Habitual debility and irritation in the 
digestive organs are particularly apt to give rise to such affeotions in 
persons of a plethoric and nervous habit of body. I was consulted, 
about eighteen months ago, by a gentleman of a very nervous tem- 
perament and weak digestive powers, for aid, in what he was led 
to regard as a local affection of the heart. The slightest mental 
agitation would, occasionally, immediately excite vehement palpi- 
tations ; and frequently similar paroxysms came on about two hours 
after talcing his meals. He had paid little or no attention to the 
regulation of his diet, although often disturbed with flatulency, 
acidity, and other unpleasant sensations in the stomach. He was 
directed to take four grains of blue pill every other evening, an oc- 
casional dose of rhubarb in the morning, and put on a light and 
digestible diet, with exercise on horseback. In four weeks his com- 
plaint left him, and he has not had any return of it since. 

Irritation located in other organs, as the kidneys, intestinal canal, 
uterus, liver, and probably the spleen, sometimes gives rise to severe 
fits of palpitation. They are particularly apt to occur about the age 
of puberly in young females, or just before the eruption of the 
menses Nervous females, more especially those who labour under 
chronic hysteric affections, are also especially subject to palpitations 
of the heart. These cases are in general easily distinguished from 
organic affections of the heart, but as structural disease of this organ 
may be associated with mere sympathetic irritation, it may be well 
to state more explicitly the signs by which nervous palpitation may 
be distinguished from'hypertrophy or dilatation of the heart. 



264 DISEASES OF THE HEART. 

Violent and extremely alarming cases of cardiac disease, uncon- 
nected with organic lesion, sometimes result from the unnatural and 
enervating practice of onanism. I have met with a most deplora- 
ble instance of this kind, in a young man, which was finally re- 
moved by discontinuing this degrading habit, in conjunction with 
mild tonics, active exercise, and a regular, digestible, and nourish- 
ing diet. Dr. Krimer has, within a few years past, published several 
remarkable cases, illustrating the injurious effects of self-pollution 
on the heart. The usual symptoms in cases of this kind, are : pale 
and dejected countenance; eyes sunken and haggard; taciturnity 
or pusillanimity ; general languor of the body, and mental apathy; 
more or less tenderness in the epigastrium ; and irregular action of 
the heart, with frequent paroxysms of tumultuous palpitation, dysp- 
noea, and precordial anxiety.* 

As the subject is one of great importance, I subjoin the following 
observations from Dr. Krimer's paper, as diagnostic of cardiac affec- 
tions arising from onanism. The hair is dry, not glossy, split at the 
extremities, and apt to fall off, especially from the fore part of the 
head. The eyes dull, sunken, watery, and apathetic ; the edges of 
the lids are often red, and the lower margin of the orbit surrounded 
with a bluish streak ; the countenance is unsettled, timid, and the 
patient " cannot bear the steadfast gaze of another person." There 
is often headache, which returns, in most instances, at nearly the same 
time daily — the pain of which radiates from the occipital to the frontal 
region. Vision is, at times, confused or dim; the appetite weak and 
capricious ; the tongue lightly covered with white fur ; and the breath- 
ing is usually short. Pain in the stomach is almost continually pre- 
sent, and the epigastrium is extremely tender to pressure " without 
any other symptoms of mucous inflammation of the stomach" 
Great lassitude with pain in the loins and lower extremities, are very 
common symptoms. There is often a considerable drowsiness, and 
always a remarkable disinclination to mental and corporeal action.t 

" In nervous palpitation, the first impression conveyed by the ste- 
thoscope is, that the heart is not enlarged. The sound, though clear, 
is not heard loudly over a great extent of the chest ; and the impulse, 
though appearing considerable at first, is really not great, as it never 
sensibly elevates the head of the observer. This last sign seems to 
me the most important and certain of any, when taken in conjunction 
with the frequency of the pulsations. These are always quicker than 
natural, being most frequently from eighty-four to ninety-six in the 

* The reviewer of Dr. Krimer's paper observes : " The disgusting nature of the 
subject has prevented English writers from any description or investigation of 
the phenomena ; but we are well convinced, from many cases which have pre- 
sented themselves to our observation, and where the cause has been voluntarily 
confessed, or unexpectedly drawn forth, that a great number of cardiac affec- 
tions, as well as anomalous symptoms of disorder in other parts of the system 
are owing to this destructive vice." — Med. Chir. Rev., April, 1828, p. 149. 

t Hufeland ; s Journal der Heilkunde, Jan., 1827. 



DISEASES OF THE HEART. 265 

minute. Nervous palpitations are rarely accompanied by any sign 
of determination of blood to the head or chest, except in old persons. 
A feeling of internal agitation, particularly in the head and abdomen, 
always accompanies nervous palpitation ; and the urine is generally 
limpid and watery." (Laennec.) 

Treatment.. — The treatment must of course be regulated accord- 
ing to the particular condition of the general system, and the local 
organic irritations that may exist. The digestive functions must be 
particularly attended to, and the sources of intestinal irritation obvi- 
ated by gentle aperients. In relaxed and weak habits, the tepid bath; 
a mild, digestible, and nutritious diet; gentle tonics, especially bitters 
and iron, gentle exercise by gestation ; and in young and plethoric 
subjects, small abstractions of blood, warm pediluvium, and digitalis, 
will, in general, prove beneficial. Antispasmodics very rarely procure 
any relief, and indeed much more frequently do injury. Although 
small portions of blood may sometimes be beneficially abstracted in 
robust and plethoric subjects, yet blood-letting, to any considerable 
extent, is generally detrimental, in the sympathetic affections of the 
heart. I have met with several instances, where repeated abstractions 
of blood had reduced the patients to the most deplorable condition ; 
and which were afterwards cured by tonics, gentle exercise by ges- 
tation, the tepid shower-bath, and a digestible and nourishing diet. 
One young man, of a dyspeptic habit, was affected at times with 
alarming palpitation, and dyspnoea. His physician, regarding it as 
active hypertrophy, bled him copiously. The disease, however, gra- 
dually became more distressing, and the blood-letting was repeated 
from time to time. Finally the patient was obliged to remain in his 
room, and could not walk across the floor without bringing on a vio- 
lent paroxysm of palpitation and prgecordial distress. A consultation 
was called, and the plan of treatment changed. Mild tonics, dry 
frictions of the extremities, the tepid shower-bath, a nourishing, but 
light and digestible diet, were ordered. In a few weeks he could 
leave his room ; soon was able to take exercise in a carriage, and in 
about three months had his health perfectly restored. Physicians are 
too apt to resort to the lancet when they find the heart in a state of 
tumultuous action. The minutest inquiry into the origin and charac- 
ter of the disease should always be instituted before this practice is 
adopted; and where there is reason to believe that the cardiac disorder 
is the result of a sympathetic irritation, blood should not be abstracted 
unless some especial indications exist for the reduction of the mass of 
the circulating fluid. When sympathetic disease of the heart is inti- 
mately connected with general plethora, which is indeed frequently 
the case, it may be proper to practise one bleeding in the commence- 
ment of the treatment; but even in cases of this kind I should prefer 
reducing the volume of the blood, by a more spare diet, and the en- 
couragement of the ordinary secretions, particularly those of the skin 
and kidneys. 



266 ANGINA PECTORIS. 



Sect. II.— Angina Pectoris.* 

Angina Pectoris was not noticed as a distinct disease, until the 
attention of the profession was directed to it by Dr. Heberden, in a 
very perspicuous and full account of its peculiar character, published 
in the second volume of the Medical Transactions of the London 
College of Physicians. Since that time, it has been frequently and 
minutely described, and of late years especially, its phenomena and 
pathology have received much attention. 

This disease consists of sudden paroxysms of pain and pressure at 
the lower part of the sternum, or about the region of the heart, extend- 
ing across the breast to the left shoulder, and to the arm as low as the 
insertion of the deltoid muscle, or the elbow, or even to the fingers; 
accompanied with some difficulty of breathing, great anxiety, and a 
sense of impending suffocation. 

The attack usually commences without any premonitions of its 
approach, by sudden pain and constriction in the left side of the chest, 
or near the scrobiculus cordis, and a peculiar numbness with more or 
less pain in the left arm, particularly on the inside, as low as the 
elbow. If the paroxysm comes on while the patient is walking, he 
is instantly obliged to stand still. The least exertion gives rise to 
intense darting and constrictive pain in the cardiac region ; and the 
patient feels as if an attempt to move would inevitably cause imme- 
diate death. During the paroxysm, the countenance is pale and ex- 
pressive of great anguish, the extremities are cold, the heart palpitates 
violently, there is more or less dyspnoea, turgidity of the vessels of the 
head, and in some instances syncope and even convulsions ensue. 
Sometimes the pain passes up along the neck and face, or back to the 
spine, with a sense of retraction at the lower end of the sternum ; and 
occasionally it is felt in both arms at once. At first the paroxysms 
last but a few minutes; and recur at remote intervals, generally in 
walking up hill, or rapidly ascending stairs soon after taking a full 
meal. By repetition, however, they become more and more violent 
and protracted, and return, in aggravated instances, on the slightest 
bodily exertion. When the attack has passed off', the patient usually 
feels only numbness of the left arm, with some degree of palpitation, 
and, occasionally, slight headache, hurried respiration, and anxiety 
of feeling in the praecordia. 

Pathology. — This disease is very rarely met with in young people, 
and it occurs, indeed, but seldom in individuals under forty years of 
age. I have, nevertheless, seen a well-marked case in a young man 
of an arthritic habit, who was not more than twenty-three years old; 
and I am now attending a girl under eleven years of age, who is 

* This disease has been described under a great variety of names, as anlhm 
convulsium, by Eisner; arthritis diaphragmatica. by Butler: syncope anginosa, by 
Parry; asthma spastico arthritkum inconstans, by Stoeller; strenalgia. by Baumes; 
sthenocardia, by Brera; asthma dohrificum, by Darwin : slernodynia syncoptica etpal- 
pitante, by Sluis; pnigophobia. by Svvediaur; and cardodync spasmodica. by Ilarles. 



ANGINA PECTORIS. 267 

occasionally seized with paroxysms which appear to me genuine 
instances of this affection.* 

The majority of cases of angina pectoris occur in individuals of a 
gouty or rheumatic habit. Jahn states, that in the summer of 1814, 
lie met with several instances of this disease, which supervened ap- 
parently as sequelae of typhus fever.t 

In relation to the immediate or exciting causes of this affection, 
pathologists have expressed very different opinions. Heberden, 
Kreysigi and Parry § attributed the disease to ossification of the 
coronary arteries, and this opinion is still entertained by many phy- 
sicians. Others have ascribed it to ossification of the semilunar valves 
of the heart; and various other organic affections of this organ and of 
the adjoining parts have been mentioned as its cause, such as morbid 
dilatation and softening of its structure ; ossification of the cartilagi- 
nous portion of the ribs ; suppurative inflammation of the mediasti- 
num, and disease of the pericardium. That no one of these morbid 
conditions, however, can be regarded as the proximate or .essential 
cause of angina pectoris, is evident from the fact, that in many fatal 
instances of the disease, no such structural disorders are discovered 
on post-mortem examination.! M. Recamier, principal physician at 
the Hotel Dieu, has never witnessed an instance of ossification of the 
coronary arteries in the bodies of those who have died of angina 
pectoris; and he wholly rejects the idea of its depending on organic 
cardiac disease. If M. Laennec, also, denies the necessary connection 
between organic affections of the heart and angina pectoris. " In a 
slight and middling degree," he says, " this disease is very common, 
and exists very frequently in persons who have no organic affection 
of the heart or large vessels."** It must, moreover, be observed, that 
ossification of the coronary arteries, and other structural diseases of 
the heart, are frequently met with in subjects who had never experi- 
enced any of the characteristic symptoms of angina pectoris. Mr. 
Cook says, " I have met with numerous instances of ossification in 
the coronary arteries, which had never been attended with symptoms 

* [I once attended a young gentleman of this city, 21 years of age, who had 
been intemperate in his habits, and subject also to inflammatory rheumatism 
which had been translated to his heart, and produced the symptoms of pericarditis. 
The consequence was the development of a genuine angina pectoris, which came 
«n in frequent and terrible paroxysms, and finally destroyed him on a voyage for 
the recovery of his health in the Gulf of Mexico. — Mc] 

t Klinik der Chronischen Krankheiten, bd. iv, p. 406. 

X Die Krankheiten des Herzens, 2 Th., 2 abhand., 5 Kap. 

$ Treatise on Syncope, Anginosa, &c. 

II [An eminent gentleman of the bar in Philadelphia, died some years ago of 
a paroxysm of this disease, and on a post-mortem inspection, I could discover no 
"thw signs of organic disease than a small patch of opacity in the serous mem- 
brane covering one of the ventricles. He had been subject in previous years to 
regular attacks of gout. — Mc] 

H Medico-Chir. Rev., March, 1829, p. 573. 

** On the Diseases of the Chest, last edition ; translated by Dr. Forbes. 



268 ANGINA PECTORIS. 

of angina ;"* and Mr. Shaw observes, in relation to this subject, that 
he had often found the coronary arteries like tubes of bone in old 
people who never had the slightest symptoms of this disease.! The 
occasional spontaneous removal of the disease, and its susceptibility, 
in some instances, of being cured, militate also directly against the 
doctrine of its necessary dependence on organic affections of the heart. 
Laennec avers that "he has known many individuals who had suf- 
fered a few very severe but short attacks of angina pectoris, and had 
had no further return of it." Dr. Parry, who believed that the dis- 
ease was always caused by ossification of the coronary arteries, never- 
theless mentions a severe case, that was wholly or nearly cured by 
the use of the bath waters. Dr. Baillie also met with two patients 
affected with symptoms "exactly resembling those of angina pectoris, 
who ultimately recovered entirely."! 

Unquestionably, however, ossification of the coronary arteries, and 
other organic cardiac affections, are very frequently connected with 
angina ; " but nothing proves, even in such cases," says Laennec, 
" that the disease depends on affections of this kind, inasmuch as they 
are of various kinds, and as the angina exists without them." 

A softened structure, or flabby and dilated state of the heart, is 
almost as common in this affection as ossification of the corouaries. 
In a most severe case, which was seen by Dr. Latham, Dr. Bree, and 
Dr. Johnson, the heart on dissection was found " pale, flabby, and 
so lacerable as to be easily mashed between the fingers like wetted 
paper or putrid meat."§ Dr. Johnson states, that in all the cases 
which occurred in his own practice, where post-mortem examination 
was made, there was a flabby and softened state of the muscular 
structure of the heart, connected in a few instances with ossification 
of the coronary arteries. || Dr. Cook also mentions a peculiar fiac- 
cidity and softness of the structure of the heart, " as a phenomenon 
usually found after this disease," sometimes with, and at others with- 
out the ossification of the corouaries or cardiac valves. T Hypertrophy 
or dilatation of the heart, without any other organic disorder, is men- 
tioned by Laennec as no uncommon condition in this affection. About 
six years ago 1 attended a gentleman in consultation with Dr. M'Clel- 
lan, who was frequently affected with violent paroxysms of angina 
pectoris. Jn one of the attacks he suddenly expired. On dissection, 
the heart was found very large, and its structure so soft as to be 
easily broken down by pressure between the fingers. 

From these facts, it appears evident that organic affections of this 
kind are to be regarded rather as the exciting than as the essential 
and proximate cause of the disease. It is now believed by many that 
angina pectoris consists in a neuralgic affection of the heart, or of 

* Treatise on the Digestive Organs, p. 274. 

t Manual of Anatomy. 

% Lectures and Observations on Medicine, p. 185. 

k Med. Chir. Rev., April, 1826, p. 497. 

II Med. Chir. Rev., March, 1828, p. 430. 

TI Loc. cit. 



ANGINA PECTORIS. 269 

the cardiac plexus ; and there can, I think, scarcely exist a doubt of 
the correctness of this opinion. Laennec conceives that the location 
of the nervous irritation may vary according to circumstances. " For 
instance," he says, " when there exists at the same time pain in the 
heart and lungs, we may presume that the affection is principally 
seated in the pneumogastric nerves; on the other hand, when there 
is simply a sense of stricture of the heart, without pulmonary pain or 
much difficulty of breathing, we may consider its seat to be in the 
nervous filaments which the heart receives from the grand sympa- 
thetic. Other nerves are also simultaneously affected, either by sym- 
pathy, or from direct anastomosis; for example, the branches of the 
brachial plexus, particularly the cubital, are almost always so ; the 
anterior thoracic nerves originating in the superficial cervical plexus 
are also frequently affected; and it is also sometimes the case with the 
branches derived from the lumbar and sacral plexuses, as we find the 
thigh and leg now and then participating in the pain and numbness." 
M. Recamier also considers this disease as a species of neuralgia ; and 
the same opinion is expressed by Dr. Johnson,* Jahn,t Jurin, De- 
sportes, and other writers. 

Mr. Teale refers the various symptoms of angina pectoris to a 
primary affection of some portion or portions of the spinal marrow, 
and the corresponding ganglia of the sympathetic. His reasons for 
adopting this opinion are : 1. The fact that most of the morbid phe 
nomena exhibited in the extreme branches or filaments of nerves, 
are seldom owing to disease in the nerves themselves, but to an 
affection of the nervous mass from which they are derived ; 2. The 
tenderness or pain on pressing some portion of the spine, in most 
cases of angina pectoris; and the correspondence of the tender part of 
the spihe with the particular symptoms which are present — namely, 
tenderness in the lower dorsal portion of the spine, in conjunction 
with constriction and other affections of the stomach; and tenderness 
in the cervical part of the spinal column, with pains in the arms, 
breast, and shoulders, and palpitations ; 3. The relief obtained, by 
counter-irritating and depletory measures applied to the spine — that 
is, to the lower dorsal portion, when the stomach is particularly 
affected, and to the cervical portion, when there are palpitations and 
affections of the arms, shoulders, &c.J 

Although this neuralgic affection of the heart may often depend 
on primary spinal irritation, as well as on organic cardiac disease, it 
may doubtless, also, be excited by other remote causes or irritations 
of the system. There are some well-authenticated facts on record, 
exemplifying the occasional dependence of this disease on dyspeptic 
irritation. I have already adverted to the two cases mentioned by 
Dr. Baillie, which ultimately recovered, and were evidently depend- 
ent " upon an imperfect digestion." Mr. Cook, also, to whose ex- 
cellent work on the diseases of the digestive organs I have referred 

*Med. Chir Rev. ; Nov., 1828, p. 197. 

fLoc. cit., bd. v, p. 407. 

X A Treatise on Neuralgic Diseases, &c. By Thomas P. Teale, Esq. 



270 ANGINA PECTORIS. 

above, thinks that angina pectoris is occasionally excited "by de- 
rangement of the digestive organs, especially by dyspepsia." Several 
eminent writers have supposed that the disease depends on gouty 
irritation ;* and Lentint maintained that it is always of rheumatic 
origin. This, with some modification, appears, also, to be the opinion 
of Dr. Chapman; and there can be no doubt that a gouty or arthritic 
diathesis is often manifestly present, in those who are subject to this 
alarming cardiac affection. From all that has been ascertained, there- 
fore, in relation to this subject, it would seem that angina pectoris may 
be excited by various causes, both organic and dynamic, and that it 
consists essentially in a peculiar irritation of the cardiac nerves, giving 
rise to pain, and more or less spastic action of the respiratory muscles. 

Treatment.— When once fully developed, angina pectoris is an 
extremely unmanageable affection, and almost always sooner or later 
terminates in death. It must not, however, be regarded as a hope- 
less affection, even in its most aggravated form; for instances of 
complete recovery have occurred, after the disease had continued for 
several years in occasional paroxysms of great severity. 

For the relief of the paroxysm, we may have recourse to small 
bleedings, anodynes, and antispasmodics. Ether, camphor, opium, 
hyoscyamus, and the liquor ammoniac succinate, have been most 
recommended for this purpose. I attended a patient some years ago, 
who was frequently seized with violent paroxysms of this affection, 
and who generally obtained considerable relief from a draught of 
very cold water. This patient died suddenly in one of the attacks; 
and on dissection, the semilunar valves of the heart were completely 
ossified. Perfect rest need scarcely be enjoined, for patients are 
irresistibly constrained to remain quiet during the paroxysm. It 
would appear even that where the patient can summon up sufficient 
firmness of mind to continue walking when the attack comes on, 
the exertion has a tendency, in some instances, to mitigate the pain 
and constricted respiration, f Dr. Good advises that the patient be 
immediately placed in an inclined position, with the head raised 
high; and an emetic instantly administered. If the pain and diffi- 
culty of respiration continue after the vomiting, " opium intermixed 
with camphor, ether, or other diffusible antispasmodics, should be 
freely employed." Emetics were, I believe, first recommended in the 
paroxysm of this disease by Percival.§ Richter admits that much 
relief may sometimes be obtained from vomits ; but he asserts that 
they may also readily do a great deal of harm. Where the oppres- 
sion in the chest is great, and the habit robust and plethoric, blood- 
letting will occasionally afford some relief. According to Laennec, 
however, leeches applied to the epigastrium or region of the heart, 
sometimes prove more beneficial than venesection. Indeed, venesec- 

* Berger, Abhandl. f. Pract. Aerzte., b. x, p. 715. Hesse, Specimen Inaugurale 
Medicum de Angina Pectoris. 

t Beitrage sur Ausiibenden Arznei\vissenschaft ; b. i. 

t Parry's Treatise on Angina Pectoris. 

§ Medical and Philosoph. Comment., vol. iii ? p. 180. 



ANGINA PECTORIS. 271 

lion may very readily prove injurious in this complaint, and it ought 
not to be used, unless the indications for its employment are unequi- 
vocal. Dr. Parry, who particularly advocates the practice of venesec- 
tion in this complaint, advises that the blood " should be taken from 
a small orifice, the patient being placed in the horizontal position, 
while the physician is to keep his finger on the pulse, to decide the 
limits to which venesection is carried." Advantage may also be 
obtained, during the paroxysm, from derivative applications, such 
as sinapisms to the legs or soles of the feet, and over the epigastrium, 
and rubefacient frictions to the lower extremities.* 

For preventing the return of the paroxysms, various remedies and 
modes of treatment have been recommended. As the cardiac irrita- 
tion may be wholly symptomatic of gastric disorder, it will be pro- 
per, in all instances, to pay particular attention to the biliary and 
digestive functions. A mild diet, the occasional use of small por- 
tions of blue pill, chalybeate mineral waters, and tepid or cold bathing, 
are particularly indicated in cases attended with dyspeptic symptoms. 
In individuals of a gouty or rheumatic habit, much advantage, it is 
said, has been obtained from the protracted use of guaiacum.t 

Goodwin states that he derived very great advantage from the 
frequent application of a strong solution of tartar emetic in spirits of 
camphor ;% and cases have been published which go to show that 
the establishment of a permanent drain from the region of the heart, 
by a seton or issue, may be resorted to with considerable prospect 
of benefit. § Baumes speaks highly of the internal use of phosphoric 
acid in this complaint ; and thinks it capable of arresting the process 
of ossification; || an opinion which was also entertained by Richter.T 
It is given to the amount of a drachm and a half daily in the form 
of lemonade. In Hufeland's Journal, a writer speaks in the highest 
terms of praise of the extract of lactnea virosve. Sixteen grains of 
this extract are to be dissolved in two drachms of cinnamon water, 
of which fifteen drops must be taken every two hours.** Arsenic 
has been used with considerable benefit by Richter ; and Smith em- 
ployed small doses of James's powder in union with castor and 
assafetida, with very good effects in some cases of this complaint.tt 
The celebrated Odier of Geneva restricted his patients to an extremely 
spare and simple diet, as the best means, in his opinion, for prevent- 
ing the return of the disease. Laennec asserts that the magnet is 

* [I have sometimes derived great advantage from cupping between the 
shoulders and over the epigastrium. In debilitated subjects, dry cupping by the 
use of common tumblers, exhausted of air by the aid of combustible matters in a 
state of flame, is the best application. — Ma] 

t Berger, loa cit., bd. p. 708. 

X Annales de Literature Medicale Etrangere, vol. iv, as quoted by Richter. 

$ New York Medical and Physical Journal, Dec, 1814. 

II Annales dc la Societe Pratique de Montpellier, torn. xii. 

H Specielle Therapie, vol. v, p. 195. 

** Journal, &c, 1809, st. i, p. 57. 

tt Medical Commentaries, Edin., vol. v, p. 78 



272 INDIGESTION. 

one of the best means for palliating or preventing the paroxysms of 
angina pectoris that we possess. He uses it in the following manner: 
" I apply," he says, " two strongly magnetized steel plates, of a line 
in thickness and of an oval shape, and bent so as to fit the part, one 
to the left precordial region, and the other exactly opposite on the 
back in such a manner that the magnetic current shall traverse the 
affected part. This method has succeeded better in my hands in the 
case of angina than any other, as well in relieving the paroxysm as 
in keeping it off. After a certain time, the magnetism most com- 
monly produces an eruption of small pimples, which are sometimes 
so painful as to oblige us to interrupt the process for some days. 
This eruption almost always takes place under the anterior plate, 
and cannot, therefore, be attributed to the action of the oxydized 
pieces of steel on the skin. By means of these plates, applied to 
the epigastrium and spine, I stopped at once a hiccup which had 
lasted three years. At the end of six months, the patient having 
one morning neglected to put on the plates, the hiccup returned, but 
was removed on their being replaced." When in angina the relief 
obtained from the magnet is but small, its good effects may be in- 
creased by previously blistering the part to a small extent, to which 
the anterior plate is applied. 

In the management of this affection, it is all important that the 
patient abstain from spirituous drinks, and avoid strong mental emo- 
tions of every kind. Inordinate venereal gratifications, too, are in 
general decidedly injurious; and strong corporeal exertions, particu- 
larly walking up hill, or rapidly ascending stairs, as well as sudden 
atmospheric vicissitudes, indigestible and irritating articles of food, 
must be carefully avoided. 



CHAPTER VI. 



CHRONIC DISEASES OF THE ALIMENTARY CANAL. 

Sect. I. — Indigestion. 

Indigestion occurs so frequently, and is attended with so discom- 
forting a train of symptoms, that it has the strongest claims upon the 
attention and sympathy of the physician. The habitual dyspeptic 
is indeed truly miserable. His sallow and anxious countenance, his 
irritable and sullen taciturnity, his aversion to social enjoyments, and 
the occasional overwhelming despondency of his mind, show him to 
be the prey of deep and harassing sufferings, of which none but 
those who have experienced them can form an adequate idea. Com- 
mon, however, as indigestion is, and serious as are its consequences 
upon the health and happiness of man, there is perhaps hardly any 



INDIGESTION. 273 

other malady which is so commonly misunderstood, and consequently 
mismanaged. 

In order to obtain a correct view of the pathology of indigestion, 
and of the true indications for its remedial management, it is neces- 
sary to be acquainted with the physiology of the process of diges- 
tion. I can here, however, advert only to the prominent and essen- 
tial circumstances in relation to this subject. It appears, then, to be 
satisfactorily demonstrated, that the two following conditions are 
essential to the regular and healthy performance of the functions of 
digestion. 

1. A due tone and peristaltic action of the muscular coat of the 
stomach, in order that the food may be uniformly embraced by the 
parietes of this organ, and as it successively undergoes chymification, 
where it is in contact with the stomach, be pushed forward towards 
the pylorus into the duodenum. 

2. The regular secretion of a sufficient quantity of healthy gastric 
juice. That the fluid called gastric juice is really the solvent which 
converts the aliment into that pultaceous mass called chyme, and 
that, therefore, digestion, so far as chymification is concerned, is 
chiefly effected by the agency of this fluid, is, I think, established 
beyond all dispute. The experiments of Spallanzani, of Stevens, 
of Gosse, and those quite recently performed by Tiedemann and 
Gmelin of Hiedelberg, and by Leuret and Lassaigne of Paris, have 
placed this physiological fact beyond all reasonable doubt. 

It does not appear, from some late experiments, that the bile has 
any material agency in the process of chymification. According to 
the experiments performed in relation to this point by Mayo, Brodie, 
Leuret, Lassaigne, Tiedemann, and Gmelin, chymification appears 
to go on perfectly in animals after the biliary duct has been tied. 
The principal agency of the bile in digestion, it would seem, is to 
render the fatty substances of the chyme soluble in the chyle. It is 
the fat or oil thus suspended, by means of the alkaline properties of 
the bile, that gives to the chyle its milky colour. When the common 
duct is tied, chymification goes on regularly, but the chyle in the 
lacteals and thoracic duct is transparent and of a yellowish hue. 

Causes of indigestion. — It has just been said that the immediate 
cause of indigestion consists in a vitiated or deficient secretion of the 
gastric juice, and in deficient or irregular action of the muscular coat 
of the stomach. Now as both muscular motion and secretion are 
under the immediate influence of the nervous power, it is obvious 
that whatever causes morbid excitement in the nervous structure of 
this organ, must necessarily tend to derange the healthy performance 
of these two functions. Accordingly, every thing which is capable 
of causing indigestion does so either by interrupting the regular 
supply of nervous influence to the stomach, or by irritating the nervous 
extremities of the mucous membrane of this organ; or by producing 
both these effects simultaneously. 

Of these former kind of causes, namely, those that interfere with 
the regular transmission of nervous influence to the stomach, are the 
mental emotions. It is surprising how suddenly any temporary 
VOL. ii. — 19 



274 INDIGESTION. 

mental agitation depresses, nay, often wholly suspends for a time the 
keenest appetite and powers of digestion. These temporary depres- 
sions of appetite and powers of digestion from sudden emotions of 
the mind, are converted into protracted and exceedingly unmanage- 
able cases of dyspepsia, when the mental perturbations are of a 
chronic and depressing character. Protracted grief and despondency 
seldom fail to weaken the digestive powers and to bring on, ulti- 
mately, confirmed and unyielding indigestion. 

Protracted and intense application of the mind, especially when 
attended with a sedentary mode of life, is another of those causes 
which act through the medium of the general system. Such, indeed, 
are the sympathetic relations of the stomach with the whole and 
every part of the organization, that its functions become disturbed by 
whatever causes either general debility or organic disorder of any of 
the principal organs of the body. 

But by far the most common and powerful causes of indigestion 
are those that act directly upon the nervous extremities of the mucous 
membrane of the stomach. Whatever is calculated to cause perma- 
nent irritation in this membrane, has a direct tendency to produce 
this disease. I think it may be assumed as a pathological axiom, 
that the functions of secretion can never be deranged without the 
existence of irritation in the secreting organ. Irritation of the vas- 
cular extremities that secrete the gastric fluid, exists therefore in every 
case of indigestion. The causes which most frequently give rise to 
this irritation consist of over-distension of the stomach and indigestible 
and irritating articles of food. The manner in which food of this 
kind produces the irritation in question, is easily to be understood. 
When the food resists the digestive powers too long, besides its direct 
irritating impressions upon the stomach, it enters more or less into 
the fermentative process, and evoives new combinations, such as gas, 
acidity, &c, which enhance the irritating qualities of the contents of 
the stomach. Besides these consequences of too long a retention of 
imperfectly digested food in the stomach, the muscular powers of this 
organ will be diminished by the long and continued exercise to which 
it is subjected, as well as by the over-distension and irritation caused 
by the gas. Portions, too, of the half-digested food will pass into 
the duodenum, which, being altogether uncongenial to the sensibility 
of this organ, will give rise in it to irritation, spasm and pain, and by 
sympathy, functional derangement of the liver. When this state vpj 
things is once produced by some error in diet, assisted, perhaps, by 
general causes, the slightest causes — even the ordinary digestible and 
plain diet taken in health — will not only sustain it, but often increase 
its violence, if favoured by other circumstances of a debilitating 
character. 

Dr. Philip thinks that over-distension of the stomach, by eating 
too much, is one of the most common causes of dyspepsia, and there 
can be no doubt as to its decided tendency in this way. It is pro- 
bable, however, I think, that it is not so much by an over-distension 
of the muscular coat of the stomach which a superabundance of in- 
gesta produces, that indigestion is caused, as by the mere excess of 



INDIGESTION. 275 

food beyond what the stomach is capable of digesting. Suppose the 
utmost powers of the stomach to be capable of digesting sixteen 
ounces of food at a time; it is manifest, that if twenty ounces are 
taken, some of it will remain either in a partially digested, or wholly- 
undigested state in the stomach, a longer time than is compatible with 
the healthy condition of the organ. The portion will therefore irri- 
tate the gastric nerves — enter more or less into a state of chemical 
decomposition, and give rise to deficient or vitiated secretions in the 
stomach, as well as debility of its muscular tunic. The effects which 
follow the reception into the stomach of an undue proportion of food, 
besides those of mere over-distension, do not differ from those which 
are caused by indigestible articles of diet. A small portion of food 
which resists the digestive powers, is capable of bringing on violent 
dyspepsia, by remaining in the stomach beyond the period which is 
allotted by nature to the process of digestion, and becoming thereby 
a source of irritation in the manner already mentioned. Just so does 
it happen when the portion of food, however digestible, is greater 
than the stomach is capable of digesting at a time : for the portion 
which remains in an undigested state, and which the stomach is no 
longer able to convert into chyme, will act like so much indigestible 
food, and give rise to the distressing consequences which often result 
from such articles of diet. 

The causes which most commonly occasion the reception of more 
aliment into the stomach than its powers are capable of converting 
into chyme, are : 

1. Eating too fast. — Dr. Philip has satisfactorily explained the 
way in which rapid eating tends to cause persons to take more food 
than they are able easily to digest. «' The appetite subsides only in 
proportion as the gastric juice becomes mixed, and as it were, neu- 
tralized by the food. When we eat rapidly, time is not given to the 
gastric liquor to combine with that part of the food which is presented 
to it; the sensation of hunger therefore continues, and we continue 
to eat until so much food is taken that the whole gastric fluid which 
the stomach is capable of supplying during the digestive process, is 
not sufficient to effect the due chymification of it. Whereas, when 
we eat slowly, so that a proper time is given for the combination to 
take place, the appetite abates before the stomach is overcharged. 
Every one has occasionally observed, that if his meal is interrupted 
for ten or fifteen minutes after having eaten perhaps not one-third of 
the usual quantity, he finds that he is satisfied. The gastric fluid 
which had accumulated has had time to combine with, and be neu- 
tralized by the food he has taken. It is for the same reason that a few 
mouth fuls of food taken a little before dinner, will often wholly 
destroy the appetite, especially in delicate people in whom the gastric 
fluid is secreted in small quantity, or of a less active quality." 

2. Imperfect mastication acts in the same manner, and as it is 
always connected with rapid eating, contributes greatly to this latter 
cause. 

3. The use of condiments, stimulating drinks, and high-seasoned 
food. These excite an artificial appetite, and keep up the desire for 



276 INDIGESTION. 

food longer than it would be sustained by the impressions simply of 
the gastric fluid. 

The free use of very cold or warm drinks, particularly during 
meals, tends much to weaken the digestion, and to aid other causes in 
the production of dyspepsia. By drinking freely, the gastric fluid is 
so much diluted that its powers are weakened, and of course the 
process of digestion more or less retarded. A very mixed diet — 
especially if the articles are of unequal degrees of digestibility— is a 
frequent cause of indigestion. 

I have stated above, that a tardy peristaltic action of the muscular 
coat of the stomach, by which the digested portions of food are too 
long retained in this organ, is very often concerned in the production 
of dyspeptic symptoms. I am persuaded, however, that the reverse 
condition also very frequently obtains, in cases of painful and imper- 
fect digestion — namely, that the food is too rapidly hurried through 
the stomach into the duodenum, before it has had time to undergo the 
full action of the gastric fluid. This appears most commonly to be 
the case in confirmed instances of the disease — or in such as are 
attended with a high degree of irritation, or a sub-inflammatory con- 
dition of the mucous membrane of the primae vise. 

That a morbid peristaltic activity of the stomach often exists in 
dyspepsia, may be inferred from the consequences which are known 
to result from high irritation or phlogosis of the mucous membrane 
of the intestinal tube. The phenomena of indigestion in aggravated 
cases also confirm the correctness of this opinion. It is a common 
circumstance, for instance, to hear dyspeptics complain of a sense of 
fullness in the stomach after eating even a small portion of food. But 
notwithstanding this feeling of repletion, they soon complain again of 
the customary sense of emptiness in the region of the stomach, and 
crave more food. It is to be observed, likewise, that the chief distress 
or uneasiness in such cases, is not experienced in the stomach, but 
rather in the region of the duodenum. Many dyspeptics feel no par- 
ticular uneasiness until an hour or two after eating, when they begin 
to experience pain and distension in the duodenum. In some cases 
the food is speedily hurried off by the bowels in an imperfectly di- 
gested condition, under very severe suffering from tormina and flatu- 
lent distension of the intestines. m 

In some instances, severe and obstinate dyspeptic affections depend 
on a primary irritation of some portion of the spinal marrow, or of the 
roots of some of the spinal nerves. " Many cases of dyspepsia," 
says Mr. Teale, " which had resisted the usual mode of treatment, I 
have found to be connected with tenderness, on pressing some of the 
middle or lower dorsal vertebrae, and on removing the tenderness in 
the spine and neighbouring parts, by proper remedies, the stomach 
affection and attendant symptoms have been almost immediately 
removed." In addition to the ordinary symptoms of indigestion, 
patients affected in this way usually complain of a peculiar sense of 
faintness or sinking at the epigastrium, and a tightness or constriction 
along the inferior margin of the chest. In some instances, also, the 
patient is frequently much harassed with flatulency of the stomach. 



INDIGESTION. 277 

This flatulency, says Mr. Teale, differs from that which arises from 
the decomposition of food so common in disorders of the stomach, by 
the rapid and copious formation of the air. The stomach is often, 
almost instantly, greatly distended with flatus, even when there is no 
obvious cause for its production. Sometimes the collection of air 
occurs more slowly, continuing for many hours or even days. Mr. 
Teale states that he has in some instances known firm pressure on 
the painful or tender part of the spine instantly to cause a sudden 
copious formation of flatus in the stomach. 

Symptoms and course. — The symptoms of indigestion differ con- 
siderably according to the stage of the complaint, or the degree and 
extent of the irritation. In the commencement the appetite is varia- 
ble, generally weak, and often entirely destroyed ; the patient is 
troubled with flatulency, distension, acid eructations, and colic pains; 
the mind is, at times, depressed and languid ; the tongue covered 
with a white fur; the bowels usually constipated; the whole system 
languid, particularly during the process of digestion; and there is 
almost a constant uneasy feeling in the epigastrium. Sometimes the 
appetite is morbidly craving, but if the patient indulges freely in tak- 
ing food, he becomes much oppressed, and generally suffers severe 
pains some hours after eating. After the disease has continued for 
some time, or has been aggravated by some unusual irritating cause 
applied to the stomach, the pulse becomes tense and quick ; the 
epigastrium tender to the touch; the mind irritable, discontented and 
gloomy. The colic pains, some time after taking food, are more fre- 
quent and severe; the bowels become irregular — being sometimes 
constipated ; at others affected with diarrhosa, during which, portions 
of food are occasionally passed off in an imperfectly digested state — 
the stools varying in colour, consistence, and character. The body 
now begins to waste, and the strength fails ; the epigastric distress 
becomes severe and constant; the countenance assumes a haggard and 
sallow aspect, the patient complains of more or less difficulty of lying 
on the left side, the skin becomes dry and shriveled, and there is 
usually a morbid sensibility to low temperature. 

From the extensive sympathies which subsist between the stomach 
and every other part of the living body, dyspeptics are frequently 
much harassed by painful and other distressing affections in parts 
situated remotely from the stomach. Among these sympathetic affec- 
tions of indigestion, headache is the most common and annoying. Dr. 
Warner observes, that there are two sorts of dyspeptic headache, the 
one occurring while the process of chymification is going on slowly 
and imperfectly in the stomach, and the other after the chyme has 
left the stomach and passed into the duodenum. The former is dis- 
tinguished by a languid and feeble pulse, a slightly coated and whit- 
ish tongue, with very pale red edges, mistiness before the eyes, slight 
vertigo, and an apprehension of falling; slight nausea and uneasiness 
in the stomach ; a sense of constriction about the fauces ; and some- 
times a coldness and numbness of the fingers ; and generally a feeling 
of weight in the brain. The second, or as Dr. Paris calls it, duodenal 
dyspeptic headache, is characterized by brilliant ocular speclra 



278 INDIGESTION. 

which constantly distress the patient; by the chilliness of the body, 
and the coldness and dampness of the hands and feet. The pain in 
the head is very severe, and is attended with a sensation of coldness 
and tension of the scalp, and a sense of weight and distension in the 
eyeballs. The tongue is commonly covered with a yellowish-white 
fur, and is often much coated. The pulse is natural in frequency, but 
always languid. There is usually flatulency, and Dr. Paris states 
that a peculiar feeling of dryness and inactivity of the bowels, as if 
the intestines had lost their sensibility and were unable to propel their 
contents, giving rise to a peculiar sensation of weight and obstruction, 
may be regarded a pathognomonic of this variety of the affection. 
These headaches rarely continue longer than two or three hours, and 
are usually diffused throughout the whole head. 

In a practical point of view, it is of great importance to bear in 
mind that dyspepsia may depend on two distinct morbid conditions 
of the digestive organs: namely, 1. On functional debility of the 
stomach from deficient or vitiated secretion of the gastric fluid, and 
muscular inactivity, independent of vascular irritation or inflamma- 
tion. 2. On deficient or vitiated secretion of the gastric fluid, with 
vascular irritation or chronic inflammation of the mucous mem- 
brane of the stomach and duodenum, and a morbidly increased peri- 
staltic action of these organs. 

The characteristic symptoms of the former grade of indigestion 
are, weak appetite ; tongue covered with white fur ; absence of epi- 
gastric tenderness, except after a paroxysm of colic from flatulent 
distension; costiveness ; acid and fetid eructations; absence of habit- 
ual tension and febrile irritation of the pulse; and the ability of 
bearing lean and tender animal food better than vegetable and fari- 
naceous articles of diet. 

The phenomena which characterize the second or inflammatory 
grade of the disease, are tenderness to pressure of the epigastrium, 
and particularly about the region of the pylorus and duodenum; a 
red, chapped, granulated or glossy appearance of the tongue; a firm, 
tense, small, and somewhat accelerated pulse, with slight manifesta- 
tions of febrile exacerbations towards evening; emaciation ; irregular 
action of the bowels, with frequent attacks of mucous, bilious or 
watery diarrhoea; violent and protracted pain in the lower part of 
the epigastrium during the process of digestion ; fullness about the 
edge of the false ribs on the right side ; and anxious and discontented 
expression of the countenance ; and inability, without great suffering, 
to endure animal food and stimulants. It appears that the irritatioti 
or chronic inflammation of such cases is seated in the mucous mem- 
brane of the pyloric extremity of the stomach and of the duodenum, 
connected usually with a congested state of the liver, and often with 
faecal accumulations in the colon. Hence the region of the duode- 
num and pylorus is almost invariably somewhat distended, and very 
tender to pressure in such cases; and these circumstances, together 
with the tense and quick pulse, furnish the most certain diagnosis 
of the existence of high mucous irritation or chronic inflammation 
in dyspeptic complaints. 



INDIGESTION. 279 

In some instances, the pain and tenderness extend across the 
epigastrium into the left side, and become fixed in the region of the 
6pleen, or where the colon turns down to form the descending arch. 
The pain and tenderness in the left side appear to depend on various 
causes, " all of which," says Dr. Philip, "are more unfavourable 
than the circumstances which cause its existence in the region of the 
pylorus and duodenum."* It may depend on an inflamed and en- 
gorged condition of the spleen, in which case this viscus is generally 
found in an enlarged condition. It arises, also, sometimes, from en- 
largement of the left lobe of the liver, " which is always the part of 
this organ most affected in indigestion." According to the observa- 
tions of Dr. Philip, however, the most common cause of the pain 
and tenderness in the left side is the extension of the chronic in- 
flammation from the pylorus to the other parts of the stomach. 

There is generally much difficulty in distinguishing pain and ten- 
derness seated in that part of the colon which lies over the pylorus, 
from the same affections in this portion of the stomach and duode- 
num. " The best means for distinguishing affections of the stomach 
from those of the colon, are the digestive process in the latter case 
being better performed ; the state of the bile being less disordered; 
the patient not experiencing the increase of uneasiness which often 
comes on after meals, for a considerable time after eating, and often 
experiencing more or less pain, or some other uneasiness in the re- 
gion of the stomach a short time before the bowels are moved, and 
more or less relief soon after their action." (Philip.) Pain and ten- 
derness on pressure cannot, however, be regarded as an unequivo- 
cal sign of inflammation in the pylorus and duodenum. This part 
sometimes becomes morbidly sensitive, without capillary congestion 
or inflammation. Nevertheless, where we find this tenderness a 
little below and to the right of the pit of the stomach, at the same 
time that the sides and tip of the tongue are red, with a granulated 
surface and a dry streak in the middle, together with a tense and 
quick pulse, we may be assured that the parts just mentioned are 
in ;i state of inflammation. 

Treatment. — One, of the first things to be attended to when we 
are called to prescribe in a case of dyspepsia, is to obviate, as far as 
possible, the usual exciting causes of this distressing affection ; and 
with this view, we must direct our attention chiefly to the adoption 
of proper dietetic regulations. In all cases of dyspepsia, whether 
simple or complicated, mild or violent, an undeviating observance of 
suitable regulations in relation both to the quantity and quality of the 
aliment, and the manner of taking it, is absolutely indispensable to 
success in the management of the risease. The patient should be 
directed to masticate well and slowly; to take his meals at regular 
hours ; to eat no more at a time than is just sufficient to sustain the 
powers of the system ; to drink but little during and for a short time 
after taking food ; and he must avoid taking any active exercise 

* On the Treatment of the more Protracted Cases of Indigestion. London 
1827, p. 19. 



280 INDIGESTION. 

during the first stage of the process of digestion. The presence or 
absence of symptoms indicative of high irritation or sub-inflamma- 
tion in the mucous membrane of the stomach and duodenum will 
enable us to say, almost with certainty, whether an animal or vege- 
table diet will procure most relief to the patient ; but in relation to 
the particular articles of these two kinds of aliment, no specific direc- 
tions can be given which are applicable to all cases: for some dys- 
peptics are benefited by certain articles of food that are altogether 
intolerable to others. This is more especially apt to be the case in 
those habitual dyspeptic cases which depend on mere functional 
debility, with morbid sensibility of the stomach, unconnected with 
inflammation. In some cases the dyspeptic symptoms are excited 
only by particular aliments; "and we must endeavour to ascertain 
whether a peculiar idiosyncrasy of the stomach prevails in such in- 
stances, or whether there is a debilitated condition of the organ 
that incapacitates it from digesting any food demanding considerable 
powers for its chymification." Every individual affected, and suffer- 
ing under this grade of dyspepsia, must in a great measure learn 
from his own experience, what articles of diet will or will not agree 
with him. In general, however, where the disease depends more on 
debility of the digestive organs, without a fixed tenderness and full- 
ness in the epigastrium, the more digestible kinds of animal food, 
are decidedly the most proper. In such cases, a plain abstemious diet 
of this kind, together with the occasional use of gentle aperients, mild 
tonics, regular exercise, and a rigid avoidance of the usual exciting 
causes of the complaint, will rarely fail to establish a cure, or at least 
to procure an exemption from its more disturbing symptoms. Mini- 
mal is undoubtedly much more digestible than vegetable food ; and 
where the gastric irritation is not considerable, it will very generally 
be taken with the least inconvenience by dyspeptic persons. We may 
lay it down, therefore, as a general principle, that animal food is the 
most proper ; and of this the most tender muscular parts are to be 
selected. There is nothing to be apprehended from the stimulant 
qualities of animal food, in cases depending on debility, without any 
particular morbid irritability or phlogosis of the digestive organs. 
Our object here is to obtain the most digestible food, and which is, 
at the same time, the least apt to enter into fermentative decompo- 
sition. By a food of this kind, the debilitated stomach is moderately 
excited, and subject to less labour ; while the chyme is more speedily 
and perfectly formed, and the development of acid flatus, &c, thus, in 
a great degree, prevented. It is very different, however, with those 
cases of protracted and inveterate dyspepsia that are attended with a 
red tongue, tender and somewhat tumid epigastrium, and a firm pulse. 
Here the food, as I shall presently state more particularly, must be 
as bland and as unirritating as possible. 

Much attention has been directed to inquiries concerning the com- 
parative digestibility of the various customary articles of food. All 
agree that the flesh of old animals, with the exception of beef and veal, 
is more digestible than that of young animals. The latter contains 
much more mucilaginous matter than the former; and all mucilages 



INDIGESTION. 281 

are of difficult digestion. Animal jellies, and young meats, observes 
Dr. Philip, are what is commonly called light food, with a reference 
to their stimulating qualities, or tendency to excite fever — and hence, 
in persons recovering from fever, or in extremely irritable habits, 
we prescribe the animal jellies, or young meats which contain them 
in abundance, in preference to the meats of old animals. In dyspep- 
sia, however, from mere gastric debility, animal jellies remain long 
in the stomach, from their indigestible nature, and cause therefore 
more disturbance and distress than beef or mutton. Tender beef, 
mutton, and all kinds of game — more especially — venison are usually 
of easy digestion, and generally agree much better with dyspeptics dur- 
ing the early stages of the disease, than any other article of diet. Pork 
and veal are, with most persons affected with indigestion, altogether 
inadmissible ; and fish, too, seldom agrees well except when taken 
in very small portions, and in a boiled state. The most oppressive 
kinds of poultry are geese and ducks; and "turkey is more oppressive 
than fowl, which, next to mutton, is, perhaps, upon the whole, the 
lightest animal food in common use, if the skin be avoided.'''' Pheas- 
ant is the least easy of digestion of the different kinds of wild game; 
but partridge and hare are in general readily digested by weak sto- 
machs. Soft-boiled eggs will sometimes agree very well with dys- 
peptics ; but care must be taken not to eat the coagulated portions of 
the albumen. Simple rousting or boiling is the best way of pre- 
paring meat for persons labouring under indigestion— -fried articles 
of food being in general very oppressive. There is no aliment more 
offensive to a weak stomach than new made bread. By mastication 
it is converted into a tenacious paste, which "is not easily pervaded 
by the gastric juice," and is therefore always very slowly converted 
into chyme. The bread used by a dyspeptic person should always 
be several days old : and, for a change, crackers, or "pilot bread," 
may be used. Some individuals derive much advantage from 
the employment of bran-bread, but 1 have reason to think that 
where there exists a morbid sensibility of the stomach, it is generally 
decidedly injurious. The only benefit that can be obtained from 
bran-bread beyond what may be derived from common bread, arises 
from its gently stimulating the bowels, and keeping up regular alvine 
evacuations; but I have known it to produce disagreeable irritation 
both in the stomach and bowels, by the small cuticular scales of the 
grain which it contains, and which are almost insoluble in the gastric 
ffuid. Cheese, milk, cream, and butter, unless taken in very mode- 
rate portions, are apt to become oppressive. I have known dyspeptic 
individuals, however, who were much benefited by the habitual use 
of cream and crackers at their meals. Fresh vegetables are very 
generally injurious, particularly cabbage, peas, beans; and above all, 
cucumbers, lettuce, celery, and other articles of this kind taken in the 
form of a salad, or in an uncooked state.* Of fruits, pears, currants, 

* [The capaciousness of some dyspeptic stomachs is remarkable enough. I 
have known several cases in which raw turnips and radishes, and even cucum- 
bers, could be eaten with impunity when the best selected articles of diet would 



282 INDIGESTION. 

gooseberries, whortleberries, and melons, are generally most apt to 
prove injurious. Mealy potatoes and turnips are among the best arti- 
cles of this kind for dyspeptic subjects. All kinds of pastry— such as hot 
cakes, pies, puddings, &c— are entirely out of the question. The food 
of a person labouring under dyspepsia from gastric debility, should 
be chiefly taken in a solid state. Soups and broths very rarely do well 
in cases of this kind. I have already stated, that slow eating and 
perfect mastication are all-important observances in dyspepsia, and 
that but very little drink should be taken during, or soon alter meals. 
Moderate portions of brandy and water usually answer well in slight 
cases of indigestion, but in the more aggravated forms of the disease, 
they are exceedingly improper. Simplicity in diet, too, is of great 
importance to the comfort of dyspeptics ; and what is of equal, if not 
still greater importance, is, to take but moderate portions of food into 
the stomach at each meal. 

It must not be forgotten, that the foregoing dietetic observations 
apply only to those cases of indigestion which are free from a mor- 
bidly sensitive and irritable or an inflamed condition of the digestive 
organs. The signs by which these conditions may be detected have 
already been mentioned; and it is of the utmost importance to form 
a correct diagnosis on this subject. So far from solid animal food 
being the best aliment in cases of this kind, nothing but the lightest 
farinaceous articles of diet can be borne with any degree of comfort, 
or are compatible with the restoration of the healthy state of the 
stomach. 

These cases must indeed be treated in every respect as instances of 
chronic gastro-enteritis, and the observations that I have made with 
regard to the diet in these affections, are therefore fully applicable to 
inveterate cases of dyspepsia. 

Medicinal treatment. — When the disease depends on functional 
derangement from mere debility or inactivity of the digestive organs, 
the bowels are generally torpid, and loaded with feculent matter, and 
hence an important indication in cases of this kind is to procure 
regular alvine evacuations by diet if possible ; if not, by the occa- 
sional use of gentle aperients. When first consulted in dyspepsia 
of this grade of gastric disorder, it will in general be necessary to 
prescribe a laxative sufficiently active to evacuate the bowels freely; 
but when the infarcted state of the alimentary canal has once been 
removed, the gentlest articles of this kind, and in doses barely suffi- 
cient to procure one or two consistent evacuations, should alone be 
employed. If, indeed, the action of the bowels can be regularly 
maintained by dietetic regulations, it ought always to be preferred 
to the exhibition of laxatives. This, however, can rarely be ade- 
quately done, and almost all dyspeptics find it necessary to resort 
more or less frequently to remedial means for procuring regular alvine 
evacuations. Rhubarb, in union with some aromatic or stimulating 

always disagree. Dr. Chapman, in his excellent chapter on indigestion, relates a 
curious case of this kind, in which an exclusive diet of green corn effected a 
cure after every thing else had been rejected. — Mc] 



INDIGESTION. 283 

substance, will in general answer well as an aperient in such cases. 
The following pill* may be taken a short time before the principal 
meal; and where there is much acidity in the stomach, the rhubarb 
may be advantageously given in combination with from ten to twenty 
grains of the carbonate of soda, or with thirty or forty grains of mag- 
nesia. No remedy, however, has appeared to me to act more favour- 
ably as an aperient in the milder grades of habitual dyspepsia than 
small doses of ipecacuanha in union with aloes and the extract of hyos- 
cyamus. From personal experience, I know that in some instances 
at least, the effects of this combination are peculiarly soothing and 
sufficiently aperient.t 

Emetics were formerly much employed in dyspepsia ; but except 
in recent attacks from a surfeit or very irritating and indigestible 
ingesta, their use is now very properly almost universally condemned. 
Where it may be deemed advisable to excite vomiting we may gene- 
rally effect this purpose by copious draughts of lukewarm water, or 
what is still better, strong infusions of chamomile flowers, or of the 
eupatorium perforatum. When these do not procure adequate eme- 
sis, an ordinary dose of ipecacuanha may be administered. Tartar 
emetic is decidedly objectionable, even under the strongest indications 
for the employment of an emetic in dyspepsia. Where the disease is 
connected with morbid sensibility of the stomach, or with chronic 
inflammation, no circumstance, perhaps, can justify the exhibition of 
an emetic. 

In the grade of indigestion now particularly under consideration, 
besides the dietetic measures already indicated, and an attention to 
the regular maintenance of the alvine evacuations, mild tonics in 
combination with alkalies, gentle exercise, and the avoidance of the 
usual exciting causes of the disease, will generally restore the healthy 
functions of the digestive organs. A weak infusion of columba or 
of gentian, with a portion of the carbonate of soda, or of potash, 
may be employed for this purpose. The ferruginous preparations 
also are often peculiarly beneficial in cases of debilitated digestive 
powers, without any prominent hepatic derangement. The tartrate 
of iron, given in union with a small portion of ipecacuanha, has done 
much good in my hands in no inconsiderable number of cases.J The 
chalybeate mineral waters, also, will occasionally procure more benefit 
in instances of this kind than any other tonic. The white mustard 
seed has of late years been a very fashionable remedy for dyspepsia, 

* R. — Pulv. rhaei gr. ii. 

aloes gr. ss. 

capsici gr. i. — M. To be made into a pill. 

t U. — G. aloes soccot. ^i. 
P. ipecac, gss. 

Extract, hyoscyamus 9 i. — M. Divide into twenty pills. Take one at 
night on going to bed. 
X U. — Tart, ferri 3L 

Pulv. ipecac, gr. v. — M. Divide into three equal parts. Take one 
every morning, noon and evening. 



284 INDIGESTION. 

and in cases of simple languor and weakness of the stomach, very 
considerable advantage may in general be derived from them. Four 
or five teaspoonfnls of the unbruised seed should be taken during the 
course of the day. I have known several individuals habitually sub- 
ject to slow and painful digestion with torpor of the bowels, much 
benefited by this remedy. It need scarcely be observed that where 
the stomach is morbidly irritable and tender to pressure, this article 
cannot be taken without injurious consequences. Tonics are fre- 
quently much abused in this affection, and may readily do much 
mischief where there is great irritability of the stomach or a state of 
phlogosis, and especially where the hepatic functions are prominently 
deranged. They can be employed with a prospect of advantage 
only in cases of torpor or weakness of the digestive organs. Indiges- 
tion seldom continues long, even in its milder grades, without involv- 
ing the liver in functional disorder; and hence, alterative doses of 
mercury have of late years been among the most common means in 
dyspeptic affections. Where, from the icterode state of the eyes and 
skin, and the appearances of the stools and urine, there is reason to 
suspect the existence of functional disorder of the liver, the use of 
alterative portions of the blue mass is decidedly indicated, and will 
generally afford benefit. From four to six grains of the blue pill 
may be taken every second or third night, with an occasional dose 
of some gentle laxative — such as small portions of rhubarb, or one 
or two Seidlitz powders, or a few of the laxative pills already men- 
tioned. I have been much in the habit of giving the blue mass in 
union with a laxative, according to the following formula ; and gene- 
rally, as it appeared to me, with more advantage than when they 
are given separately and at distinct periods.* Care must be taken, 
however, in prescribing mercury in this affection, not to continue its 
use until the general system becomes affected ; for general mercurial 
excitement is always improper in dyspepsia. Some individuals are 
always very disagreeably affected by the blue pill. I have met with 
dyspeptic patients in whom this mercurial invariably excited the most 
unpleasant sensations in the stomach, as well as great general rest- 
lessness and nervous irritation. When this is the case, we may 
generally gain our object by the internal use of the nitric acid diluted 
in a large portion of water ; or what has appeared to me still more 
advantageous, the nitro-muriatic acid bath, in the way mentioned 
under the head of chronic hepatitis.t 

As palliatives, alkalies and opium are the best remedies we possess 

* K- — Massae hydrar. gi. 

G. aloes soccot. Qiss. 

Tart, antimonii gr. ii. — M. Divide into twenty pills. Take one every 
other night on going to bed. 

t [The domestic remedy for dyspeptics which was so generally prescribed by 
the late Dr. Physick, has become quite popular in this country. It consists of a 
lixivium of one quart of hickory ashes and a teaspoonful of soot in a gallon of 
water. A wineglassful of this ley given three times a-day, is supposed to afford 
all the advantages derivable from a combination of potassa and creasote.— Mc] 



INDIGESTION. 285 

—the former for removing the burning and aching sensations which 
are caused by acidity in the stomach, and the latter for allaying the 
colic pains that result from the irritation of the food, flatus, and acid 
in the stomach and duodenum. It is to be observed, however, that 
opium cannot be frequently employed in this affection without still 
further impairing the digestive powers of the stomach ; but the pains 
are so often extremely violent, that we are obliged to resort to this 
narcotic for relief. In those cases of dyspepsia which are connected 
with a high degree of morbid sensibility of the mucous membrane of 
the stomach and duodenum, the occasional use of this anodyne is 
peculiarly valuable. Without it, indeed, patients labouring under this 
variety of dyspepsia, would enjoy but few moments of exemption 
from suffering. Dr. Philip recommends Dover's powder, and advises 
that from two to four grains of it should be given every six or eight 
hours. This will commonly be sufficient to allay the general nervous 
irritation which is apt to occur in cases of this kind ; but when those 
violent gastric and duodenal pains come on which at times rack the 
unfortunate dyspeptic, nothing but the largest doses of laudanum will 
be sufficient to allay his extreme suffering. I have known persons 
in the utmost degree of agony for hours, from irritation in the stomach 
and duodenum, who were obliged to take several hundred drops of 
laudanum before relief was procured; and in this respect, I may, 
indeed, truly say with the poet — 

Atque utinam numero ne nos essemus in isto. 

Weak and slow digestion is frequently connected with a morbid 
sensibility of the nerves of the stomach and duodenum, independent 
of chronic inflammation of these organs. When the patient is subject 
to severe pains an hour or two after taking a meal — and more espe- 
cially when the gastric distress is particularly excited by certain articles 
of food which usually agree with other dyspeptics, and when, more- 
over, the edges of the tongue remain of a pale red, with a thin white 
fur over the middle, and the pulse is free from tension, though quick 
and small, and the skin generally soft, and below the natural tempe- 
rature ; and, finally, when with these symptoms there is a disagreea- 
ble or painful feeling of emptiness experienced in the region of the 
stomach four or five hours after taking food, without any particular 
tenderness to pressure on the epigastrium — when these symptoms 
exist, there is reason for believing that an exalted sensibility of the 
gastric nerves is present without phlogosis. The diagnosis in relation 
to these circumstances, is of much more importance, in a practical 
point of view, than seems to be generally supposed. Dr. Philip speaks 
particularly in favour of the employment of ammonia, in what he 
calls the second stage of indigestion, and it is, indeed, in many cases, 
deserving of all the encomiums which he has bestowed upon it. The 
instances, however, in which, according to my own observations, it 
is most apt to prove beneficial, are those in which there is a constant 
tendency to the generation of acid in the prima? viee, in connection 
with morbid sensibility of the mucous membrane of the stomach and 
duodenum. In cases of this kind, eight or ten grains of the carbonate 



286 INDIGESTION. 

of ammonia with five or six grains of Dover's powder may be taken 
several times during the day with much temporary benefit. Dr. 
Philip observes, thaUn cases of dyspepsia, where the surface is cold, 
the pulse feeble, with a feeling of general depression and chilliness, 
" the ammonia is invaluable ; being less apt than any other stimulus 
of the same power, with respect to the nerves, to excite the heart and 
blood-vessels; which, from the tendency of the disease, (in this the 
second stage,) are inclined to a degree of excitement beyond that 
undue proportion to the state of the other powers." Much relief may 
also be obtained, in cases where the disorder is attended with much 
irritation and sensibility of the gastric nerves, from the liq. ace/at. 
ammonite, in union with small doses of laudanum, or of the tincture 
of hyoscyamus. A tablespoonful of the former, with ten drops of 
either of these narcotic tinctures, may be taken two or three times 
daily. 

When there is much gastric irritation, with slight febrile symptoms 
towards evening, such as dryness and heat of the skin, burning in the 
palms of the hands and the soles of the feet, and tension of the pulse, 
the nitrate of potash will generally afford considerable relief. It may 
be advantageously given with minute portions of the tincture of ipe- 
cacuanha, dissolved in some mucilaginous fluid. From five to ten 
grains of the nitre, dissolved in a few ounces of barley-water, or of a 
solution of gum Arabic, with 50 drops of tinct. ipecac , may be given 
every four hours. 

When the gastric irritation has assumed the character of chronic 
inflammation — that is, when in addition to the general symptoms just 
mentioned, the epigastrium becomes tender to pressure, the pulse tense 
and firm, and the edges and tip of the tongue red, tonics, purgatives, 
animal food, and all stimulating remedies, are no longer admissible 
Leeching or blistering over the region of the pylorus and duodenum 
is here one of the most important remedial measures. The latter, 
indeed, will often be found particularly beneficial in cases attended 
only with high irritation, without actual inflammation. For the re- 
moval of that morbidly sensitive condition of the gastric nerves noiiced 
above, there is, perhaps, no remedy so effectual as the application of 
a blister over the epigastrium. I have known patients who could 
scarcely take even the blandest articles of food without suffering a 
great deal of pain, enabled to digest light aliment with tolerable com- 
fort after having the region of the stomach blistered. Pustulation 
with the tartar emetic ointment, may also be resorted to with a fair 
prospect of advantage in such cases. Leeching, however, is always 
an excellent preliminary to vesicating or counter-irritating applica- 
tions. There is but little advantage to be obtained from internal 
remedies in cases of this kind; yet the nitrate of potash, dissolved in 
a large portion of some mucilaginous fluid, will occasionally assist in 
removing the dry and constricted state of the skin, and the distressing 
sense of internal heat. Dr. Philip advises the exhibition of small 
doses of tar/arized antimony. 1 have, occasionally, derived some 
benefit from its administration in cases attended only with gastric 
irritation ; but I doubt much of the propriety of employing this remedy 



INDIGESTION. 2S7 

where unequivocal signs of mucous inflammation of the stomach are 
present.* Some writers recommend laxatives in this as in the milder 
varieties of the disease ; but their tendency to irritate the tender and 
phlogosed mucous membrane of the stomach and intestines, renders 
them, I think, decidedly objectionable. Slight relief will, it is true, 
usually follow the operation of a purgative, but this relief is always 
but temporary, and is very often succeeded by an aggravation of the 
gastric distress and tenderness. The same objections do not, how- 
ever, exist against the use of laxative enemata, and I do not, indeed, 
know any measure which is better calculated to afford ease, in cases 
of this kind, than the daily use of one or two mild laxative clysters. 
Functional disorder of the liver is a constant attendant in cases of this 
kind ; and it becomes necessary to employ mercurials either internally 
or by frictions on the right hypochondrium. The employment of 
mercurials, however, requires great caution in the severer cases of the 
disease; for it is not uncommon to find the blue pill, even in small 
doses, to excite considerable intestinal irritation and general uneasi- 
ness. To avoid this occurrence, we may give this mercurial in union 
with a small portion of opium, or of the extract of conium. In general, 
it will be sufficient to administer one grain of the blue mass, with half 
a grain of opium, every night on going to bed, and care must be taken 
not to carry it to the extent of causing even a soreness of the gums. 
The correction of the biliary secretion, by a gradual introduction of 
mercury into the system, is generally attended with the additional 
advantage of an abatement in the tension and contraction of the pulse, 
and a diminution of the temperature and dryness of the skin. 

After all, however, our principal reliance in cases attended with a 
high grade of irritation or chronic inflammation, consists in the use of 
a bland and unirritating liquid diet, local depletion, revulsive applica- 
tions, and the occasional use of alterative doses of blue pill or calomel, 
with laxative enemata and gentle exercise by gestation or where the 
strength of the system will admit of it, walking regularly every day, 
until a slight degree of fatigue is induced. 

Let it be constantly borne in mind, that functional derangement 
of the stomach may be the consequence of mere debility and relaxa- 
tion—or of high irritation and morbid sensibility — or finally of a 
chronically inflamed condition of the mucous membrane of the di- 
gestive organs ; and that, therefore, the mode of treatment, both me- 
dicinal and dietetic, which is proper in the first, will not answer in 
(he second, and will prove decidedly pernicious in the third of these 
varieties. In the first, our object is to increase the tone and activity 
of the stomach ; in the second, to soothe the irritation and morbid 
activity of this organ ; and in the third, to subdue inflammation, and 
obviate its consequence — structural disorder. 

* [No internal remedy can be brought into competition in this condition of 
things with small doses of the nitrate of silver, made into a pill with simple bread 
or gum Arabic. I have frequently given it in combination with extract of hyoscya- 
rnus, J to i gr. of the former to 1 gr. of the latter in each pill, repeated three times 
a day.— Mc] 



2S8 DIARRHCEA. 

It should also be recollected that disorder of the stomach, attend- 
ed with harassing symptoms of indigestion, may be the direct con- 
sequence of spinal irritation. (Teale.) In all obstinate cases of 
indigestion, therefore, the spinal column ought to be carefully exa- 
mined, in order to ascertain whether any portion of it be tender or 
painful to pressure. It cannot be doubted that spinal irritation 
sometimes produces great disorder of the digestive organs; and in 
such cases, it would be in vain to expect any relief, so long as the 
spinal affection continues. In cases of this kind, the tenderness to 
pressure is generally confined to the lower dorsal vertebrae. Should 
such tenderness or soreness be found to exist, cupping over the 
affected part of the spine, repeated, at intervals of four or five days, 
according to the obstinacy of the spinal irritation, will seldom fail 
to remove all the dyspeptic symptoms. Blisters, or rubefacient 
frictions, also, over the affected portion of the spine, will sometimes 
afford complete relief in instances of this kind. 



Sect. II. — Diarrhoea. 

Diarrhoea is an affection of the bowels, the characteristic symp- 
toms of which are : frequent and usually copious liquid stools of a 
feculent character— attended with more or less griping without 
tenesmus, and generally without febrile irritation. 

The proximate cause of diarrhoea consists, according to the sen- 
timents of Cullen and some other writers, in increased peristaltic 
motion of the intestinal tube. Unquestionably, an inordinate peri- 
staltic action does take place in this affection ; but this increased ac- 
tion does not constitute the essential pathological condition of the 
disease, and cannot therefore be properly regarded as its proximate 
cause. Increased action of the intestinal canal may arise in two 
ways, namely: 1. The irritability of the bowels may be in a natu- 
ral state, whilst the substances which are brought to act on them 
are of a peculiarly irritating or exciting character. In this case the 
alvine discharges will generally cease soon after the irritating sub- 
stances which have excited them are expelled, or their activity is 
destroyed — as is the case with the purging produced by cathartics, 
or the action of other transient irritants. 2. The irritability of the 
bowels may be preternaturally increased ; in which case, the ordi- 
nary secretions and contents of the intestinal canal, and even the 
mildest substances, will produce excessive peristaltic action, and of 
course frequent alvine discharges. 

Irritation of the mucous membrane of the bowels, therefore, 
constitutes the primary morbid condition in diarrhoea, of which the 
increased peristaltic motion and the inordinate alvine evacuations 
are the consequences. When the diarrhoea continues long, or as- 
sumes a chronic form, the mucous irritation becomes fixed, and 
unless it be counteracted by an appropriate treatment, gradually 
passes into a state of chronic inflammation— more especially of the 
mucous membrane of the colon, and finally terminates in ulceration, 



DIARRH(EA. 289 

and other forms of disorganization of this membrane. Broussais 
observes, that when diarrhoea continues beyond the thirtieth day, 
it is almost invariably connected with organic derangement of the 
mucous membrane of the colon. When the disease continues until 
the irritation passes successively into chronic inflammation and dis- 
organization of the mucous tissue of the bowels, slight febrile irri- 
tation occurs — particularly towards evening, and a few hours after 
eating; the pulse becomes quick, small, and frequent; the skin dry 
and harsh; the body emaciates more or less rapidly; and at last 
oedema of the feet and legs, and occasionally dropsical effusions into 
the cavity of the abdomen, ensue. In this aggravated form, the pa-' 
tient is apt to experience extremely severe colic pains an hour or so 
after taking food, and in general even the mildest ingesta are fol- 
lowed by tormina, flatulency, and diarrhoeal discharges, and articles 
of food are sometimes passed in the stools in an imperfectly digested 
state. The appetite is generally very variable and capricious ; being 
sometimes voracious, and at others entirely depressed. The stools, 
too, vary much both in relation to frequency and appearance. They 
are sometimes slimy, mixed with more or less fecal matter ; at others 
abundant and watery — occasionally dark, reddish, or whitish, and 
often contain small portions of undigested food. On post-mortem 
examination of subjects who have died from chronic diarrhoea, 
or from some other disease accompanied with this bowel affec- 
tion, we sometimes discover irregular patches of a fungoid appear- 
ance, and of a livid or dark red colour, slightly elevated above the 
surrounding parts, on the mucous membrane of some portion of 
the intestinal canal. In other instances, small well-defined ulcers 
with elevated edges, or extensive irregular ulcerations with ragged 
edges, are met with. Not unfrequentiy the coats of the intestines 
are thickened at the parts where these ulcers are situated ; and in 
some instances this thickening is so great as to diminish the area of 
the intestinal tube very considerably. In cases of this kind, says 
Broussais, the usual diarrhoeal symptoms are apt to alternate with 
attacks of costiveness, and death occasionally occurs under symp- 
toms resembling those of ileus. Sometimes, instead of ulcers, the 
mucous membrane is covered with numerous tuberculous elevations 
of different sizes ; and occasionally extensive portions of this mem- 
brane are found covered with smooth cicatrices of ulcerations which 
have healed. Broussais observes that these ulcerations are always 
found most numerous in the caecum, and about the lower portion of 
the colon. He thinks, and with great probability indeed, that when 
the feculent matters become fetid and putrid, whether from long 
retention or imperfect digestion, they cause irritation, and ultimately 
inflammation, in that part of the mucous membrane where they are 
most apt to become accumulated. When death occurs at an earlier 
period of diarrhoea, the mucous membrane of the colon, and of the 
ileum, is usually found in a more or less reddened or injected state, 
with slight thickening of its structure. This is particularly observed 
in those chronic diseases which, during the latter period of their 
course, are accompanied with colliquative diarrhoea. In the chronic 

VOL. II. — 20 



290 DIARRHffiA. 

diarrhoea of children, attending what is usually called marasmus, I 
have found in several instances on dissection the mucous membrane 
of the lower portion of the small intestines and of the colon, exhi- 
biting extensive tracks of a congeries of minutely injected vessels. 

Causes.— The remote or occasional causes of diarrhoea are exceed- 
ingly various. They may be divided into those which act directly 
on the mucous membrane of the intestinal canal ; and those which 
act indirectly through the medium of the general system. Of the 
former kind are all irritating substances received into, or generated 
in the alimentary canal ; and of these the most common are : irri- 
gating and indigestible articles of food and drink; acrid and vitiated 
secretions from the liver and intestinal exhalents; worms; acid gene- 
rated in the bowels ; fresh fruit, particularly such as are very sweet, 
or acid, &c. Limestone water is particularly apt to give rise to 
copious diarrhoea in those who have not been accustomed to its use; 
and new made cider, before it has undergone the fermentative pro- 
cess, is also extremely apt to excite this affection. Much, however, 
depends on the previous or habitual state of the irritability of the 
intestinal canal, with regard to the power of different articles to 
excite this affection. Some individuals apparently in a state of good 
health cannot take particular articles of diet or drink without suffer- 
ing more or less from griping and diarrhoea ; whilst in others no un- 
pleasant effect whatever will result from the same articles. Idiosyn- 
crasy also appears occasionally to be concerned in the production of 
this affection by causes of this kind. Thus in some persons, fresh 
milk almost invariably excites diarrhceal discharges ; and I know an 
individual who generally becomes affected with diarrhoea when he 
eats fresh oysters. Diarrhoea produced by causes of this kind is, 
however, almost always of temporary duration, and depends on 
simple irritation, which generally readily subsides after the offending 
matter has been discharged, and other exciting causes do not super- 
vene. Nevertheless if the bowels have previously been in an irri- 
table condition, or if the patient be labouring under some organic 
visceral affection, instances which commence from such local irritating 
causes are apt to continue, and unless particular attention be paid to 
a careful avoidance of the further influence of the exciting causes of 
this affection, to give rise to high irritation, inflammation, and finally 
ulceration in some portion of the intestinal canal. 

Among the causes of diarrhoea that affect the alimentary canal 
through the medium of the general system, cold, particularly when 
applied in a humid way to the feet or abdomen, is one of the most 
common and powerful. When produced by this cause, it constitutes 
the diarrhoea rheumatica or catarrhalis of the German writers. 
Cases of this kind are most apt to occur during damp and variable 
weather, and the evacuations are generally very liquid or watery. 
Slight rheumatic or catarrhal symptoms are apt to accompany the 
disease— such as toothache, transient pains in the extremities, short 
cough and coryza, together with slight febrile irritation, towards 
evening, attended with a dry mouth and great thirst. The tormina 
are usually exceedingly severe. The occurrence of diarrhoea from 



DIARRHCEA. 291 

cold, or the conjoined agency of humidity and cold, depends, no doubt, 
on the centripetal direction given to the circulation ; in consequence 
of which the liver and capillaries of the mucous membrane of the 
bowels become engorged with blood, giving rise to a vitiated or per- 
haps a superabundant secretion of bile and intestinal mucus, at the 
same time that the irritability of the bowels is morbidly increased. 

Diarrhoea appears also sometimes to arise from an epidemic con- 
dition of the atmosphere, independent of its thermometrical or hy- 
drometrical states. This variety of the disease usually occurs in the 
autumn when the nights begin to be cool, and after a very dry and hot 
summer, and generally during the prevalence of other forms of in- 
testinal diseases — particularly dysentery and cholera. Cases that 
proceed from causes of this kind are commonly preceded by the same 
train of premonitory symptoms that usher in miasmatic fevers — such 
as a feeling of weight and anxiety in the praecordia, loss of appetite, 
bitter taste, tension and fullness of the abdomen, disturbed sleep, 
headache, some lassitude and aching pain in the back, and slight 
sensations of creeping chilliness. (Richter.) Diarrhoea arising from 
this cause frequently passes into the dysenteric form of the disease. 
It is probable that these cases depend on the conjoined influence of 
l^oino-miasmata and atmospheric vicissitudes — giving rise to increased 
irritability, functional disorder, and sanguineous engorgement of the 
liver and intestinal canal, in a way which will be more particularly 
referred to under the head of Cholera. Besides these there are many 
other general causes capable of producing violent and protracted 
diarrhoea. The repercussion of acute and chronic cutaneous erup- 
tions sometimes gives rise to obstinate attacks of this disease. It 
may also be produced by violent affections of the mind, particularly 
sudden terror and grief. Diarrhoea occurs very frequently in visce- 
ral and other local affections attended with suppuration and ulcera- 
tive disorganization. Thus, in the latter period of pulmonary con- 
sumption, colliquative diarrhoea almost invariably occurs; and the 
same may indeed be said of every variety of disease attended with 
hectic fever, or extensive suppurations. 

In febrile diseases, diarrhoea sometimes occurs as a critical evacua- 
tion.* It can never be regarded as salutary, however, where it de- 
pends on the supervention of phlogosis, or high vascular irritation of 
the mucous membrane of the bowels. When the discharge is watery, 
reddish or muddy, mixed with flocculi of mucus, and the abdomen is 
tender and the tongue dry and red along the edges, it always indicates 
an aggravated condition of the disease, and the existence of mucous 
inflammation, and is of course a highly unfavourable occurrence. 
Critical diarrhoea appears generally to depend on a copious secretion 
of bile, or an increased discharge from the intestinal exhalents, co- 
operating, probably, with a morbid irritability of the bowels; and 
hence salutary discharges of this kind are almost invariably bilious, 

* Fr, Hoffman. Dissert, cle Diarrhoea in Febribus Malignis Morbis Acutus 
Salutari. Buchner, Dissert, de Diarrhoea in Febribus Exanthematicis Salute et 
Noxa. 



292 DIARRH(EA. 

mixed with more or less feculent matter and intestinal mucus. Wa- 
tery discharges, free from bile, are rarely if ever indicative of a favour- 
able tendency of the disease. During dentition, children are very 
liable to diarrhoea; but as this discharge, when moderate and unac- 
companied with much gastro-enteric irritation, is calculated to lessen 
the tendency to preternatural determinations to the brain, it should 
not be checked in instances of this kind, unless it becomes excessive 
and very exhausting. 

Prognosis. — When the diarrhocal discharge has been brought on 
by indigestible or irritating articles of food or drink, and consists 
principally of feculent matter and vitiated secretions, it may in gene- 
ral be readily checked, and unless greatly mismanaged, will rarely 
assume a dangerous character. In general diarrhoea is most apt to 
assume a chronic and dangerous character when it arises from the 
influence of cold and damp air, or from the habitual use of unwhole- 
some and indigestible diet, in individuals labouring under some chro- 
nic visceral affection, or whose general health has been much impaired 
by previous diseases, hardships, or a course of intemperate living. 
When we find the disease to continue long, with frequent, watery, 
and acrid discharges, attended with tenderness in the abdomen on firm 
pressure, and extremely severe tormina, we may presume that therg 
exists chronic inflammation, or at least high irritation in the mucous 
membrane of some portion of the bowels— and consequently that there 
is much danger of the occurrence of structural disorder in this tissue, it 
the disease be not soon removed by appropriate measures. Those 
cases of diarrhoea that assume a strictly chronic character, and in 
which scanty and painful diarrhoeal evacuations of an unnatural 
appearance occasionally alternate with short periods of constipation, 
and severe pains are experienced in the track of the colon an hour or 
two after eating,, may be regarded as certainly dependent on mucous 
inflammation, and most probably attended with more or less ulcera- 
tion, and consequently with great danger and difficulty in effecting a 
cure. 

Diarrhoea from the irritation of dentition, as has just been remarked, 
is rather a salutary than a dangerous affection ; but when this symp- 
tom of enteric disease is accompanied with a pale and fretful expres- 
sion of the countenance, a hard and tumid abdomen, frequent picking 
at the nose, voracious appetite, and the discharge of undigested por- 
tions of food in the stools, it must be considered as an affection of 
very serious import. 

Treatment. — In the treatment of diarrhoea it should always be 
recollected that the characteristic alvine discharges, by which this 
affection is recognized, and from which its name has been derived, 
are mere symptoms of a primary intestinal disorder, and that our 
remedies must be especially directed against this, the essential malady. 
If, then, we reflect that the local intestinal disease consists either in 
simple irritation; or in irritation with chronic inflammation ; or finally, 
in irritation with chronic inflammation and disorganization of the 
mucous membrane of a greater or less proportion of the bowels, 
according to the grade of violence and duration of the malady, we 



DIARRHCEA. 



293 



shall have no difficulty in instituting a rational plan of treatment. In 
this, as in other affections, our remedial measures must be modified 
according to the nature of the exciting cause. Thus, where the dis- 
ease is produced by suppressed perspiration from cold, the restoration 
and maintenance of the cutaneous exhalation, along with the reme- 
dies to be presently mentioned, will be peculiarly proper; where the 
irritation is produced by vitiated or redundant bile, mercurial remedies 
are especially applicable; and where a surfeit, or acrid and offensive 
ingesta have given rise to the disease, laxatives are indispensable in 
recent cases. 

The principal indications in this form of intestinal disease, therefore, 
are, 1. To remove as much as possible every source of intestinal irri- 
tation ; 2. To allay the morbid irritability of the mucous membrane 
of the bowels ; and 3. To diminish the determination of the blood to 
the vessels of the intestinal canal. 

In recent cases where there is reason to presume that the intestinal 
irritation is kept up by vitiated secretions, or other irritating matters 
lodged in the bowels, recourse must be had to mild purgatives. This 
is especially necessary where diarrhoea is the consequence of indi- 
gestion, or of the reception into the stomach of iudigestible and irri- 
tating articles of food ; or where the bowels are infarcted, or loaded 
with fecal matter, as occurs in the marasmus of children. It must be 
observed, however, that it is only in the earlier periods of diarrhoea, 
or where the mucous irritation has not passed into the state of inflam- 
mation, that any material advantage may in general be obtained 
from purgatives; and even incases depending on simple irritation, 
the gentlest laxatives alone ought to be employed. Purgatives are, 
indeed, very often greatly abused in affections of this kind. Nothing 
is more common than the repeated use of active purgatives in diar- 
rhoea. An individual becomes affected with looseness of the bowels. 
If it does not soon cease spontaneously, he takes a purge. The bowel- 
complaint, however, continues, and convinces him that there is still 
something left which must be removed. To make himself sure of 
his object he takes a more active dose; but the tormina and dis- 
charges, instead of being mitigated, acquire greater violence. Asto- 
nished at the obstinacy with which the offending matter sticks to the 
bowels, he determines, once and for all, to get rid of the cause of his 
complaint, and swallows a double dose of the most active cathartic. 
He now begins to experience tenderness in the abdomen; the tormina 
and diarrheal discharges continue; in short, he has developed in- 
flammation, which the most judicious management may not be capa- 
ble of removing. 

We cannot, however, always abstain from laxatives in instances 
manifestly connected with inflammation of the internal membrane 
of the bowels. Thus, where phlogosis or a state of irritation closely 
approaching inflammation exists in connection with an accumulation 
of feces and vitiated secretions, with a hard and tumid state of the 
abdomen — a combination of circumstances frequently met with in 
children — no hopes of procuring relief can be reasonably entertained, 
until these irritating matters are removed out of the bowels by a course 



294 DIARRHCEA. 

of gentle aperient remedies. Fortunately, in cases of this kind, we 
may, in general, gain our object in this respect much more readily, 
by "mild, than the more active articles of this kind, when assisted by 
an appropriate diet. A grain of calomel at night, and a moderate 
dose of castor oil on the following morning, assisted with three or four 
laxative enernata during the day, will in general answer well in such 
cases {marasmus), without doing any injury to the inflamed bowels. 
Castor oil is decidedly the best purgative in cases of diarrhoea, attended 
with a high degree of irritation or phlogosis. One or two grains of 
calomel, or three or four grains of blue pill, with from one to two 
grains of ipecacuanha, may be occasionally given to an adult, both 
with a view to its aperient effects, and its influence upon the biliary 
organs, which always become more or less deranged in diarrhoea of 
protracted continuance. Many writers recommend rhubarb as a suita- 
ble purge in this disease ; and in recent cases, from irritating matters 
lodged in the bowels, it will, no doubt, answer all the purposes that 
may be obtained from a remedy of this kind. In protracted instances, 
however, where there is higli intestinal irritation, or chronic inflam- 
mation, it is much inferior to the cold pressed castor oil. From its 
tonic, along with its aperient powers, rhubarb was formerly thought 
to be peculiarly suited to the treatment of this affection, under the 
erroneous notion that diarrhoea is generally the consequence of a re- 
laxation or loss of tone in the intestinal tube. Where it may be deemed 
necessary to administer an aperient in cases manifestly connected with 
chronic inflammation, or a highly irritated condition of the bowels, 
the castor oil may be very advantageously given in union with from 
fifteen to twenty drops of laudanum. 

In all bowel affections attended with inordinate discharges, a pre- 
ternatural determination of blood takes place to the vessels of the in- 
testines, with more or less torpor of the cutaneous exhalents. This is 
more especially the case in instances of long standing, and contributes 
very materially to the support of the intestinal irritation. Remedies 
which are calculated to counteract this centripetal direction of the 
humors, are therefore especially proper in affections of this kind. For 
this purpose, opium, in combination with small doses of calomel and 
ipecacuanha, constitutes an excellent remedy, after the irritating con- 
tents of the bowels have been evacuated by suitable laxatives. Opium 
and calomel have a direct tendency to allay the morbid irritability of 
the mucous membrane of the alimentary canal, and when given in 
conjunction with small portions of ipecacuanha, seldom fail to excite 
the activity of the cutaneous exhalents. In recent cases of diarrhoea, 
where the discharge depends on simple irritation of the bowels, the 
exhibition of one of the following pills every four hours, after the ope- 
ration of a dose of castor oil, will seldom fail to check the complaint,* 
Minute portions of calomel, too, will frequently arrest the progress 

* R. — G. opii gr. iii. 

Pulv. ipecac, gr. xii. 

Calomel gr. ii. 

Conserv. rosar. q. s. — M. Divide into 12 pills. 



DIARRHtEA. 



295 



of the disease. (Dr. Ayre.) From a sixth to a fourth of a grain of 
calomel may be given every hour or two. In the diarrhoea of infants, 
arising from acidity of the primse viae, and deficient biliary secretion, 
this article given in union with two or three grains of prepared chalk, 
is often peculiarly beneficial, but as the irritation is apt to be trans- 
ferred from the bowels to the brain in young children, opium may do 
mischief, by promoting the determination to the head. 

Very frequently diarrhoea is induced and sustained by impaired 
digestion in consequence of a weakened state of the stomach. Here 
alterative doses of calomel and the use of mild tonics, together with 
simple, unirritating and digestible diet, will commonly prove bene- 
ficial. 

Astringent remedies have been much employed in diarrhosa ; but 
where the mucous membrane iof the bowels is in a state of high 
irritation or inflammation, articles of this kind are almost always 
decidedly pernicious. In instances where the discharge is kept up by 
a slight degree of irritation and relaxation of the intestinal exhalents, 
benefit may occasionally be obtained from remedies of this kind; but 
even in such cases, they may in general be very properly dispensed 
with. The astringents most commonly employed in diarrhoeal af- 
fections are kino, alum, acetate of lead, sulphate of zinc, and the 
infusions of logwood, blackberry -root, the root of geranium macula- 
turn, &c. Astringents should never be resorted to where the tormina 
are very severe, and there is a tenderness or soreness to the touch in 
the abdomen. I have repeatedly known great injury done by the use 
of such articles in the ordinary bowel-complaints of children ; and 
there can be no doubt that, as a general rule, astringents deserve to 
be reprobated 'in affections of this kind. Judging from my own ex- 
perience, opium and ipecacuanha are much more efficacious than 
astringents, even in instances .which may be deemed favourable to 
the beneficial operation of the latter class of remedies. 

What I have hitherto said, refers more particularly to recent cases 
of diarrhoea, before the intestinal irritation has become fixed or con- 
verted into inflammation and its consequences. When the disease 
assumes a chronic character, it generally becomes exceedingly ob- 
stinate, and often resists every mode of remedial treatment. One of 
the most important measures in such cases is the avoidance of every 
kind of stimulating aliment. The food should consist wholly of fari- 
naceous fluids, light broths, animal jellies, rice, barley, oatmeal gruel, 
milk, &c. In all cases, indeed, whether recent or chronic, such a 
diet is decidedly the most proper ; but in the latter form of the disease, 
it is absolutely essential to success in its treatment. 

In some instances of chronic diarrhoea, we may succeed in remov- 
ing the disease by a rigid adherence to this simple and unirritating 
diet in conjunction with the employment of small doses of calomel 
and opium, the occasional use of the warm bath, leeching, and coun- 
ter-irritating.applications to the abdomen. I have in several instances 
derived great advantage from the employment of small doses of 
Dover's powder, in union with the acetate of lead, according to the 



296 DIARRH03A. 

following formula.* Not unfrequently, all the means just mentioned, 
however judiciously employed, will entirely disappoint us in our 
attempts to remove the disease. I have known instances of this 
affection to continue for nine or ten months, although all the fore- 
going remedies, together with an appropriate diet, had been diligently 
used. In cases of this obstinate character, the internal use of balsam 
copuiva will sometimes do much good. What I have already said 
under the head of chronic enteritis, in relation to this remedy, applies 
fully to the chronic form of the present affection. It is not probable, 
however, that it can procure any permanent relief in cases attended 
with ulceration of the intestinal mucous tissue ; yet even in cases of 
this kind, I have known considerable temporary benefit derived from 
this article. In a case of pulmonary hepatization, with purulent 
expectoration, attended for nine months with continued and extremely 
painful diarrhoea, the balsam copaiva emulsion generally gave very 
considerable relief for four or five days, after which the symptoms 
recurred with their usual degree of violence, notwithstanding the use 
of this medicine. On dissection, a number of irregular ulcerations 
were detected in the mucous membrane of the colon and the lower 
portion of the small intestines. In a case of chronic diarrhoea of 
upwards of six months, continuance, I succeeded in effecting a perfect 
cure by means of this remedy, given to the extent of from thirty to 
forty drops three times daily, and fifteen drops of laudanum with 
each dose. In this case, the diarrhceal discharge depended, no doubt, 
on simple chronic inflammation, without ulceration of the mucous 
tissue. Dr. Elliotson has lately introduced a new remedy to the 
notice of the profession, for the cure of chronic diarrhoea, dependent 
on ulceration, which has been employed with much success at St. 
Thomas's Hospital in London — namely, the sulphate of copper in 
union with opium. Cases that had resisted almost all the remedies 
usually accounted the most efficacious in this affection, yielded rea- 
dily to this remedy. The dose is half a grain twice a day, with a 
grain of opium, increasing the quantity of the former article gradually 
to two and even three grains in a day. From the known good effects 
of weak solutions of this preparation when applied to chronic ulcer- 
ations, it is not improbable that its operation in this way may occa- 
sionally prove very serviceable in diarrhcea depending on ulcers of 
the mucous membrane of the bowels; and although the vegetable 
astringents are always unequivocally injurious in such cases, some 
benefit may also arise from its peculiar astringent influence on the 
engorged and dilated capillaries of the mucous membrane. Mr. Kerr 
speaks very favourably of the effects of the persesquinitrate of iron 
in this affection. Several very long-standing cases yielded in a short 
time to the influence of this article. The dose, for an adult, is from 
twelve to twenty drops twice daily. t Whatever internal remedies 

* R. — Pulv. ipecac, compos. 7)i. 

Pulv. acetat. plumb, gr. vi.— M. Divide into six equal parts. S. Take 
one every four hours. 

t The following is his method of preparing this nitrate : " Take of small chips 



CHOLERA. 29' 

may be resorted to in cases of this kind, it will always be proper to 
keen up the regular action of the cutaneous exhalents-and it is 
especially useful to excite the extreme vessels of the external surface 
of the abdomen. For this purpose, a broad flannel roller should be 
constantly worn round the body, and the patient must be particular y 
careful not to expose himself to the influence of damp and cold 
weather, and above all, to avoid getting wet and cold feet. All kinds 
of alcoholic liquors must also be avoided. Mucilaginous fluids, such as 
infusion of mallows, or flaxseed, or barley water, slightly acidulated 
with sulphuric acid, form the best drink. 

Sect. III.— Cholera. (Cholera Morbus.) 

Cholera is an affection of the alimentary canal, characterized by 
very frequent and violent vomiting and purging, with severe tor- 
mina, and cramps in the muscles of the abdominal parietes and ex- 
tremities. The disease almost always comes on suddenly. Pain, 
and a sense of tension in the epigastrium, are generally the first 
symptoms by which it makes its attack. This is soon followed by 
violent colic pains about the umbilical region, accompanied with 
exceedingly distressing nausea. In a few moments after the occur- 
rence of these symptoms, vomiting and purging commence with 
extreme violence, and continue, with but very short intervals, until 
the system is exhausted, if speedy relief be not obtained. During 
the intervals between the attacks of vomiting, the patient is usually 
harassed with continual nausea, and an indescribable feeling of dis- 
tress in the epigastrium. The alvine discharges are at first thin and 
watery, and generally with little or no admixture of bile ; nor is the 
fluid ejected from the stomach usually of a bilious character, during 
the early period of the disease. After the disease has continued for 
an hour or two, however, the bile begins to make its appearance 
pretty copiously in the evacuations, and towards the conclusion, the 
fluid discharged consists, in many instances, almost entirely of bilious 
matter. As the disease advances, the tormina become more and more 
severe and continual, and the purging and retching are almost inces- 
sant. One of the most distressing affections belonging to this dis- 
ease are the extremely painful cramps which, in severe cases, occur 
in the abdominal muscles, and in those of the inferior extremities. 
In cases of no great violence, the cramps occur principally, and 
sometimes exclusively, in the muscles of the legs ; but in rapid and 

or pieces of iron wire, an ounce and a half; nitric acid three ounces by measure; 
water, twenty-seven ounces; muriatic acid, one drachm. Put the iron into an 
earthenware vessel, and pour on the nitric acid, previously diluted with fifteen 
ounces of water. Set the vessel aside till the whole of the acid has united with 
the iron, so as to form a persesquinitrate ; then decant the liquid from the portion 
of iron which remains undissolved, strain and filter. Add the muriatic acid with 
imainder of the water, or with as much of that liquid as shall increase the 
whole solution to thirty ounces.— Edin. Med. fy Surg. Journ,, vol. xxxvii, p. 99. 



298 CHOLERA. 

very severe attacks, the muscles of the trunk, as well as of the upper 
and lower extremities, are alike affected in this way. The thirst is 
always exceedingly urgent; but every thing received into the stomach 
is almost immediately thrown up again. As soon as the disease is 
completely developed, the pulse is small, feeble, irregular or inter- 
mitting ; the hands and feet become cold, the countenance pale, 
shrunk, and expressive of great distress; a cold sweat breaks out on 
the extremities and face ; and extreme prostration speedily ensues. 

Cholera is one of the most rapid and fatal forms of disease. It 
seldom continues beyond twenty-four hours, without terminating 
favourably or fatally ; and in many instances it ends in death, in the 
course of three or four hours, and sometimes in a much shorter pe- 
riod. In the cholera of India, death generally takes place within 
two or three hours after its commencement. In this extremely fatal 
variety of cholera, the patient is generally suddenly seized with great 
prostration, unquenchable thirst, a scarcely perceptible pulse, cold 
and clammy sweats, cramps in every part of the body, inexpressible 
anxiety of feeling, extreme restlessness, syncope, excruciating tor- 
mina, constant retching, and very frequent stools of a thin, whitish, 
or starchy fluid. If the patient survive this, the first stage of the 
disease, which is by no means common, some degree of reaction 
usually ensues in the course of from twenty to forty hours; and the 
liver begins to pour out an abundance of dark, thick, vitiated bile, 
which is discharged in the stools, and which may be regarded as an 
indication of a favourable crisis in the disease. 

Etiology and pathology. — A superabundance of vitiated bile in 
the stomach and bowels was formerly, and, by some, is still regarded 
as the immediate cause of this very dangerous malady. The term 
cholera* is, indeed, sufficiently expressive of the notions once uni- 
versally entertained concerning the nature of these affections. Dr. 
Cullen says, "the matter ejected, both upwards and downwards, 
appears manifestly to consist chiefly of bile;" and Dr. Gregory, 
though he rejects the idea of its dependence on a redundant and 
vitiated secretion of bile, says that the disease "commences with 
nausea and unremitted bilious vomiting" &c. In truth, almost all 
writers, up to the time of Dr. Bateman and Dr. James Johnson, men- 
tion a copious and vitiated bile as the exciting cause of this affection; 
but the erroneousness of this sentiment is now well known by all 
who have kept pace with the progress of pathological science. So 
far, indeed, from there being a redundant secretion of bile in cholera, 
there is actually a deficient formation of this fluid, from functional 
torpor of the liver ; and it would appear that the hepatic torpor is in 
direct proportion to the violence of the disease. No one, indeed, 
who has attentively observed the early symptoms of cholera, can for 
a moment doubt of the correctness of this statement ; for, however 
abundant the discharge of bile may be after the disease has continued 
for some hours, this fluid never appears in the evacuations during 
the early period, or what may be termed the first stage of the disease. 

* From x oX «; bile, and f»a>, to flow. 



CHOLERA. 299 

The observations and researches that have been published of late 
years — and they have not been limited — in relation to the pathology 
of cholera, render it evident, that the liver, and indeed the whole 
system of the portal circulation, are extremely engorged with blood. 
In the cholera of India, the liver, in subjects who die during the first 
stage of the disease, is always found enlarged, and greatly engorged 
with blood, and the internal surface of the stomach and bowels 
marked with large patches of highly injected and distended vessels. 
In the cholera of infants, I have never seen an instance in which bile 
appeared in the evacuations, except after the disease had taken a 
favourable turn; and in the few dissections which I have witnessed 
of subjects who had died of this disease, the sanguineous congestion 
of the liver, and mucous membrane of the alimentary canal, was 
very conspicuous. So far, therefore, our knowledge of the patho- 
logy of this affection appears to be sufficiently certain ; but how are 
we to account for the extreme irritability of the stomach and bowels, 
and the excessive vomiting and purging ? Can hepatic torpor and 
congestion in the portal system of vessels give rise to this morbid 
condition of the alimentary canal ? or are we to consider this state 
of the liver, and the general engorgement of the portal vessels, only 
as concomitant phenomena, and in no way causative of the cha- 
racteristic gastric and intestinal affections ? From some of the cir- 
cumstances just mentioned, it would appear, indeed, that the hepatic 
torpor and congestion have no small share in the production of gastro- 
intestinal disorder. The fact, that the symptoms almost always 
begin to abate as soon as the liver resumes its functions, and pours 
out a copious flood of bile, strongly favours this opinion. Strong 
sanguineous congestion, and torpor of the liver, are almost always 
attended with great irritability of the stomach. In the malignant 
grades of bilious fever, the vomiting, during the first stage, is often 
incessant, and extremely distressing, whilst the fluid ejected is wholly 
free from bilious matter. If death takes place in this stage, the liver 
is always found exceedingly engorged with blood, and the vessels 
of the stomach are in a similar state of congestion ; but when the 
disease continues until large evacuations of black and pitch-like 
bile take place from the bowels, an abatement of all the symptoms 
usually ensues. 

With regard to the remote causes of cholera, it is manifest that 
high atmospheric temperature constitutes the principal agents con- 
cerned in its production. In our own climate this affection appears 
almost exclusively during the warm months of summer ; but it is 
nevertheless probable that elevated temperature acts rather as an 
essential predisposing, than as an exciting cause of the disease. 
Cool and damp night air, or exposure to a current of fresh air after 
the liver and skin have been over-excited by the previous influence 
of solar heat and exercise, is one of the most common exciting causes 
of this affection. When the cutaneous and hepatic functions, while 
in a state of inordinate activity, are suddenly arrested by the influ- 
ence of cold, the blood retreats from the surface to the internal ves- 
sels ; the portal circulation becomes engorged, and the capillaries of 



300 CHOLERA. 

the mucous membrane of the bowels strongly congested. This in- 
jected or engorged state of the capillaries of the mucous membrane 
of the alimentary canal gives rise, we may presume, to morbid irri- 
tability of this structure, and, consequently, to the characteristic phe- 
nomena of the disease. Much may also depend on the influence of 
koino-miasmata in the production of this affection. The tendency 
of this agent to excite and derange the functions of the liver, is well 
known, and when operating in conjunction with high atmospheric 
heat, as it always does, its tendency to enhance the predisposition to 
this affection is, no doubt, very considerable. 

In some instances of intermitting fever, the paroxysms are ushered 
in by violent attacks of cholera, the* vomiting and purging usually 
coming on towards the termination of the cold stage, and continuing 
until the febrile reaction is fully developed. Sometimes cholera returns 
in quotidian paroxysms, commencing with a slight cold stage, and 
terminating in free perspiration, without any distinct hot stage. 

Cholera may also be excited by the direct irritation of indigestible 
and irritating articles of food and drink ; but causes of this kind rarely 
produce the disease unless the system is predisposed to it by a debili- 
tated state of the digestive organs, or by general relaxation and ex- 
haustion from the influence of high atmospheric temperature. 

Cholera Infantum. 

The cholera of infants differs in several essential points from the 
ordinary cholera of adults. It is almost always distinctly febrile, and 
very frequently commences in a gradual manner, with more or less 
diarrhoea, of several days' continuance, before the vomiting super- 
venes. It is also particularly liable to become protracted in its dura- 
tion, or to assume a chronic form, a circumstance which is scarcely 
ever noticed in the other varieties of the disease. The liver appears 
to be as inactive in this as in the preceding form of cholera; for 
when once fully developed, the evacuations, during the early period 
of the disease, are wholly devoid of any appearances of bilious matter, 
consisting either of a whitish, frothy, or of a watery, and almost 
colourless fluid. If the disease does not rapidly exhaust the vital 
powers, and terminate fatally during the first few days, the patient 
begins to emaciate; the extremities become cold; the head and sur- 
face of the abdomen extremely warm; the skin dry and harsh; the 
countenance pale and shrunk; the eyes dull and sunk; and the pulse 
small, irritated, and frequent. If the disease be not vanquished by 
proper remedial measures, the little patient, by degrees, becomes 
somnolent; he sleeps with the eyes half open, rolls about his head 
when awake, and at last sinks into a state of insensibility and coma, 
and dies, under symptoms resembling those of the last stage of hydro- 
cephalus. When the disease is very protracted in its course, aphthae 
usually appear on the tongue and inside of the cheeks; the face 
acquires an oedematous appearance; the alvine discharges become so 
acrid as to excoriate the parts about the anus; and towards the fatal 



CHOLERA. 



301 



conclusion, spots of effused blood under the cuticle, sometimes appear 
on various' parts of the surface. ,-.'■. ,. , u 

The duration of this variety of cholera is exceedingly various. It 
mav prove fatal in five or six hours ; or continue for several weeks, 
and even months, until the body is reduced to a state of extreme 
emaciation, and yet terminate favourably. The majority of deaths 
take place before the termination of the ninth day. 

When death takes place early in violent and rapid cases, the liver, 
and vessels of the mucous membrane of the alimentary canal, are 
found, on dissection, strongly engorged with blood ; " and where the 
disease had continued for some length of time before death, ulcera- 
tion and even abrasion of the lining membrane of the stomach and 
bowels," are usually discovered.* 

The etiology of the cholera of infants differs in some important 
circumstances from that of the ordinary form of the disease in adults. 
Both these varieties of cholera are almost exclusively confined to 
the hot months of the year ; but cholera infantum is vastly more 
prevalent in large and crowded cities than in the country — a circum- 
stance which does not obtain in relation to the cholera of adults. 
During a practice of twelve years in the country, I met with but 
two or three cases of this disease in infants. Again, cholera infant- 
um occurs almost exclusively between the third and twenty-fourth 
months of age ; in other words, during the period when the process 
of primary dentition is going on. There are, thferefore, three causes 
whose concomitant influence is extensively concerned in the pro- 
duction of this variety of cholera, namely, high atmospheric heat ; 
the contaminated air of crowded cities ; and the irritation produced 
by dentition. From the great prevalence of this disease during the 
hot months of summer in the more filthy parts of crowded cities, it 
has been supposed that it is of malarious origin, and " a mere 
variety of the bilious fever of our climate, the force of which is 
turned inwards upon the intestines." (Condie.) In support of this 
sentiment, it has been alleged by the respectable physician just 
quoted, that though seldom met with in salubrious districts of the 
country, « a majority of the children fall victims to cholera infantum 
in the neighbourhood of marshes, or in low, wet, and otherwise 
unhealthy situations." This, I apprehend, will not be confirmed by 
the observations of those who practice in the neighbourhood of pa- 
ludal districts. Unquestionably, cholera is much more common, 
both in infants and adults, in such localities than in high and salu- 
brious parts of the country, and there can be no doubt that mias- 
mata have a considerable tendency to favour the occurrence of cho- 
lera, whether in adults or in infancy. If, however, koino-miasmata 
be the principal agent concerned in the production of this malady, 
why is the disease so exclusively confined to a particular period of 
infancy in our cities? And why, we may further ask, d[oes it com- 

* Dr. Condie. Observations on the Pathology and Treatment of Cholera 
Infantum, &c, in the Philadelphia Journal of Med. and Phys. Sciences, Mav 
1825. ' '' 



302 CHOLERA. 

mence so early as in the latter part of June, and usually acquire its 
most extensive sway in July, before the ordinary paludal diseases are 
wont to make their appearance, except here or there perhaps a few 
instances? Let it be observed, too, that we frequently find this fatal 
disease of infants extremely rife in this city, when scarcely any of 
the other diseases justly ascribed to the miasmata in question occur 
among our inhabitants. High atmospheric temperature and the 
irritation of dentition appear to be the principal remote causes of 
this affection. But as these causes very seldom, produce cholera in 
infants enjoying the pure air of the country, there must be some 
other circumstance peculiar to populous cities which especially 
favours their tendency to develop this disease. This accessory or 
predisposing cause consists probably in the impure air of cities, by 
which the infantile system is rendered irritable, and peculiarly pre- 
disposed to suffer disturbances from the irritation of dentition. 

It seems to me highly probable that erethism of the brain caused 
by the irritation of difficult dentition in the peculiarly irritable habit 
of body just mentioned, is frequently deeply concerned in the pro- 
duction of this malady. Throughout the whole course of the dis- 
ease, the head is always preternaturally warm— and in most instances 
the child is peculiarly restless and fretful for several days previous 
to the "accession of the disease. The tendency of cerebral irritation 
to cause inordinate irritability of the stomach and bowels is well 
known. Diarrhoea is very common, and in general a salutary occur- 
rence during the process of painful dentition. In the commencement 
of hydrocephalus, great gastric irritability and frequent vomiting are 
very rarely absent. In concussion of the brain, vomiting is often a 
very troublesome symptom : and sea-sickness, which is often so vio- 
lent as to resemble cholera, appears to depend entirely on the peculiar 
cerebral excitement occasioned by the swinging or rocking motion of 
a vessel at sea. The great tendency of cholera infantum, in its chronic 
form, to terminate in a state of cerebral oppression and coma, seems 
also to show that the brain is especially predisposed to inflammation, 
or to that peculiar morbid condition which constitutes what is usually 
called acute hydrocephalus. 

We may, therefore, presume, that, in the irritable condition of the 
system produced by the influence of a very warm and contaminated 
atmosphere, dentition causes more or less cerebral irritation, which 
being reflected on the stomach and bowels, renders them preterna- 
turally irritable. If in this state of the alimentary canal, the cuta- 
neous exhalents are over excited and debilitated by high atmo- 
spheric temperature, the slightest reduction of temperature, a current 
of fresh air, or damp night air, will readily cause a sudden torpor of 
these emunctories. The blood will retreat from the surface to the 
internal organs, and give rise to engorgement of the vessels of the 
liver and mucous membrane of the bowels, by which the gastro- 
intestinal irritability will be still further increased, and the character- 
istic symptoms of the disease excited. 



CHOLERA. 303 

According to the pathological researches of Professor Horner,* 
cholera infantum consists in an inflammation of the mucous glands or 
follicles of the alimentary canal, and not in a common vascular or 
erythemoid inflammation of the intestinal mucous membrane. In 
most instances he found the mucous follicles very distinct to the naked 
eye, and their orifices enlarged and tumid. In the large intestines 
they were generally larger and more tumid, so as to present the ap- 
pearance of small grains of white sand sprinkled over the mucous 
membrane. Sometimes enlarged mieparous glands were, more or 
less, ulcerated; and in a few instances he found the follicles "converted 
into small cysts, of the transparency and size of the itch vesicle, which, 
on being punctured with a needle, and pressed, readily gave out their 
transparent fluid." The mucous membrane of the stomach and small 
intestines was, generally, of a more or less deep sienna colour — and, 
in some cases, portions of this membrane were so soft " that it could 
be very easily scraped off with the finger nail." 

Treatment of Cholera. 

The principal indications in the treatment of the cholera of adults, 
are to allay as speedily as possible the irritability of the stomach and 
bowels ; to restore the action of the skin and liver ; and to determine 
the circulation from the internal to the external parts. As the pro- 
gress of this disease is always extremely rapid, the most prompt and 
energetic means should be at once resorted to, with the view of mo- 
derating its violence ; and for this purpose we possess no remedies 
so powerful and certaiti in their effects as opium, and the application 
of a large and active sinapism to the region of the stomach and liver. 
When the disease supervenes soon after having taken a full meal, or 
some indigestible and irritating articles of food or drink, the patient 
should be directed to take copious draughts of chamomile or balm 
tea, or warm water, in order to procure the speedy evacuation of 
the irritating substances lodged in the alimentary canal. In all cases, 
indeed, it will be proper, in the commencement of the disease, to 
allow the patient the free use of bland drinks, both with a view of 
washing out the contents of the intestinal canal, and of moderating 
the painful and exhausting effects of frequent ineffectual efforts of 
vomiting and purging when the stomach and bowels are empty. As 
soon, however, as the irritating contents of the stomach and bowels 
are evacuated, a large dose of opium should be administered, and the 
patient kept from taking any drinks for at least thirty minutes after 
the medicine is taken. From 80 to 100 drops of laudanum should 
be given at once ; and the same quantity, mixed with a small portion 
of warm water, thrown into the rectum. If vomiting occurs soon 
after the first dose is taken, the laudanum should be repeated in doses 
of from 30 to 40 drops every fifteen minutes, until its influence on the 
system is fully obtained. At the same time a large sinapism must be 
laid over the right hypochondrium and epigastrium. Instead of sina- 

* American Journal of Medical Sciences. February, 1829. 



304 CHOLERA. 

pisms, we may resort with nearly equal advantage to active rube- 
facient embrocations. I have in several instances derived very 
prompt benefit from the application of the oil of manarda punctata 
to the abdomen, in conjunction with the internal use of large doses 
of laudanum. This oil is one of the most active local irritants we 
possess. When applied in an undiluted state it inflames the skin in a 
few minutes, and causes exceedingly severe burning pain in the part. 
The spirit of turpentine may also be used for this purpose, but its 
effects are less prompt and powerful than those of the ol. monarda. 
Upon the prompt and free use of opium and external revulsive appli- 
cations, our chief reliance must be placed. The practice of giving 
warm spiced brandy, and other powerfully exciting articles of this 
kind, is highly improper. Brandy maybe allowed in the latter stage 
of the disease, when the prostration is extreme, and it is absolutely 
necessary to support the sinking powers of the system by potent dif- 
fusible stimulants ; but if it be given during the early period of the 
disease, with the view of moderating the excessive vomiting and 
purging, it will not only generally disappoint our expectations but 
often manifestly aggravate the symptoms of the complaint. The 
sedative powers of opium, however, are eminently calculated to allay 
the extreme irritability of the alimentary canal, and when promptly 
and efficiently given, will seldom fail to procure complete relief in 
the course of sixty or eighty minutes. In not a single instance in 
which I have resorted to this valuable remedy, did it fail to arrest the 
vomiting and purging within the period just mentioned ; and the only 
fatal case I ever saw, was treated chiefly with warm spiced brandy. 
If from six to eight grains of opium can be introduced into the sto- 
mach, and retained for fifteen or twenty minutes, we may calculate 
almost with certainty on the speedy subsidence of the disease. When 
the laudanum is immediately thrown up again, it should be repeated, 
again and again, until its effects are obtained. I have in the course 
of an hour given nearly an ounce of laudanum in this way, before the 
gastric irritability was allayed, without any injurious consequences 
from its ultimate narcotic operation. Where this medicine is imme- 
diately rejected by the stomach, we may obtain its effects by external 
application, with almost the same promptitude and certainty as if it 
were retained in the stomach. For this purpose the cuticle should be 
removed from the epigastrium, which may be speedily done by means 
of the nitric acid, as practised by Mr. Powell in the cholera of India. 
Two parts of this acid diluted with one part of water are to be applied 
by means of a sponge upon the whole region of the stomach; and as 
soon as the patient feels considerable pain from its impressions, the 
part is to be washed with a solution of the carbonate of potash. The 
cuticle may now be easily detached, so as to leave the cutis exposed 
and raw. Upon this surface, from ten to twelve grains of morphia 
may be applied, either in the form of a plaster, or by sprinkling the 
powder over it, and covering it with a piece of linen thinly spread 
with simple cerate. By this procedure we at once obtain the advan- 
tage of a powerful counter-irritating application, and of the full influ- 
ence of the opium. When the irritability of the stomach and bowels 



CHOLERA. 305 

is in some degree allayed, it will be proper to employ calomel in 
small but frequent doses, with the view of stimulating the action of 
the liver. Haifa grain of this article may be administered every half 
hour, and continued until the alvine discharges become bilious, or the 
disease is subdued. Dr. Ayre speaks highly in favour of minute and 
frequent doses of this remedy in cholera,and there can be no question 
as to its entire adaptation to the treatment of this affection. Where 
the disease is very violent and rapid, however, we cannot depend on 
its operation without the conjoined influence of efficient doses of 
opium. It may be very advantageously given in union with pow- 
dered opium, in the proportion of two grains of each, every half hour, 
until the narcotic effects of the former are manifested, when the 
calomel should be continued alone in half grain doses. The warm 
bath may be used with occasional advantage in the commencement 
of the disease; and where the exhaustion is great, and the muscles of 
the extremities affected with severe cramps, much benefit will gene- 
rally result from rubefacient frictions— particularly from frictions with 
a strong tincture of capsicum. When the pulse sinks and the extre- 
mities become cold, the patient should be wrapped in flannels soaked 
with hot brandy, and recourse had to the internal administration of 
diffusible stimuli. One of the best articles of this kind, according to 
my own experience, is a solution of camphor in vitriolic ether. Of a 
solution of a drachm of camphor in an ounce of ether, a teaspoonful 
may be given every half hour until the reaction is considerably in- 
creased. In one instance, where the pulse was scarcely perceptible, 
and the extremities cold and clammy, this solution given in the way 
just mentioned produced the happiest effects. I have stated above, 
that drinks should be withheld for some time after administering the 
first dose of laudanum, in order, if possible, to prevent it from being 
thrown off before it can produce its impressions on the stomach ; with 
this exception, it will always be proper to allow mild mucilaginous 
fluids in a warm state — such as barley-water — as long as the vomiting 
and purging continue ; for, as has already been stated, the exhaustion 
produced by the excessive vomiting and purging, is much less rapid 
when the stomach and bowels are freely supplied with fluids, than 
when they are nearly empty, and the evacuant efforts are ineffectual 
or attended with but small discharges. 

After the disease is subdued, the patient should take light and nou- 
rishing diet, such as animal broths. It will also be proper, during the 
period of convalescence, to wear a flannel roller round the abdomen; 
and to take a few grains of blue pill, with a grain of ipecacuanha, 
every evening on going to bed ; and when the digestive powers re- 
main weak, a tablespoonful of the infusion of colomba, or gentian, or 
a wineglassful of chamomile tea, with a few grains of the carbonate 
of ammonia, may be taken three or four times daily. 

Treatment of Cholera Infantum. 

Although the morbid condition of the liver and alimentary canal, 
in cholera infantum, does not appear to differ from that of the cholera 

VOL. II.— 21 



306 CHOLERA. 

of adults, yet the treatment proper in the former, differs in several 
very essential points from that which is best calculated for the removal 
of the latter variety of the disease. Besides the indications already 
mentioned for the treatment of ordinary cholera, we have, in the 
present variety, the important one of obviating irritation and sangui- 
neous congestion of the brain; and hence opium, which is decidedly 
the most valuable remedy in the cholera of adults, cannot be employed 
without great hazard, of doing mischief in the cholera of infants. Some 
practitioners,under an idea that the stomach contains offending matter, 
which spontaneous vomiting is incapable of throwing off, commence 
the treatment with the exhibition of a gentle emetic; but this practice 
is not only founded on an erroneous view of the pathological condition 
of the alimentary canal, but what is still more to the purpose, is gene- 
rally decidedly injurious. 

From what was said above, in relation to the pathology of this 
affection, it would appear that torpor of the liver and skin, in con- 
nection with cerebral irritation, constitute the immediate cause of the 
excessive irritability of the stomach and bowels. Our principal object, 
therefore, must be, to restore these two functions; to obviate irritation 
and sanguineous congestion in the brain, and to determine the blood 
from the engorged vessels of the liver and mucous membrane of the 
alimentary canal. To answer these purposes I generally commence 
the treatment with the application of from ten to twelve leeches to 
the temples, the exhibition of minute portions of calomel and ipeca- 
cuanha, and a large stimulating poultice over the abdomen. I am 
persuaded, by what I have repeatedly observed in my practice, that 
great benefit will in general result from local depletion from the head, 
as well as from the application of blisters behind the ears, or on the 
back of the neck, in this affection. Within the last four years, I have 
not treated an instance of this complaint, in which 1 did not at once 
apply blisters behind the ears, and in most instances with unequivocal 
advantage. This at least I may confidently affirm, that since I have 
adopted this practice, I have been much more successful in the man- 
agement of this disease than previously. Where the pulse is irritated 
and the head very warm, leeching at the temples or behind the ears 
is particularly indicated, and will seldom fail to procure very manifest 
relief. In an extremely severe case which I lately attended in a child 
about eighteen months old, twelve leeches applied to the back of the 
ears, was almost immediately succeeded with great abatement of the 
violence of the symptoms. With the view of moderating the gastro- 
intestinal irritation, and of stimulating the action of the liver, minute 
portions of calomel and ipecacuanha constitute, I think, the most valu- 
able internal remedy we possess for combating this disease. From 
one-sixth to a quarter of a grain of calomel in union with half a grain 
of ipecacuanha, should be given every hour or two, and continued 
until the evacuations become mixed with bilious matter. Let it be 
borne in mind, that so long as the liver remains torpid, and the alvine 
discharges free from bilious matter, the disease may be regarded as 
still possessing all its violence and dangerous tendency, whatever 
temporary abatement may occur in the severity of the vomiting and 



CHOLERA. 307 

purging. The appearance of bile in the stools, whether green or dark, 
is always to be hailed as a very favourable sign, and the sooner the 
liver can be brought to resume its secretory action, the greater in 
general will be the probability of ultimate success in our attempts to 
subdue the disease. Ipecacuanha in small doses is a most excellent 
auxiliary to the calomel, in affections attended with morbid irritability 
and excessive peristaltic action of the alimentary canal. Its tendency 
to counteract inordinate action of the bowels, when given in small 
doses, is well known ; and its tendency also to excite diaphoresis, still 
further enhances its applicability in this and other similar intestinal 
affections. Where, from a tumid and tense state of the abdomen, 
there is reason to presume that the bowels are loaded with fecal matter, 
the quantity of calomel at each dose should be larger, so as to procure 
its purgative operation. I have occasionally given a grain every two 
hours until its evacuant effects were procured, and afterwards con- 
tinued it in doses of about one-sixth of a grain every hour. Dr. Ed- 
ward Miller appears to have been the first physician who particularly 
recommended minute doses of calomel in cholera infantum ; and under 
judicious management it is unquestionably a very valuable remedy 
in this affection. Except under the circumstances just mentioned — 
namely, a loaded state of the bowels, purgatives are not in general 
advisable in the commencement of the disease. Where the disease 
continues, however, until the liver, under the exciting influence of the 
calomel, pours out a large quantity of bile, mild laxatives are highly 
useful. In a case which I attended during the present season, the 
vomiting and purging were in a great measure arrested on the third 
day of the disease. The infant, however, sunk into a state of stupor, 
from which it was very difficult to rouse it. As the evacuations from 
the bowels were very dark and small, and the vomiting had ceased, 
I prescribed a full dose of castor oil. In about two hours after the 
oil was taken, copious evacuations of a pitch-like matter took place 
from the bowels; and the little patient was almost immediately freed 
from the alarming symptoms of cerebral oppression under which it 
laboured. Where the disease comes on gradually, and proceeds 
slowly, it may perhaps be better to commence at once with purgative 
doses of calomel, than with the minute alterative portions mentioned 
above. In cases of this kind, the bowels are, frequently, much loaded 
with fecal matter, which it is of much importance to evacuate, as 
speedily and completely as can be done without resorting to very 
active or irritating purgatives. 

At the same time that the means already indicated are employed, 
external revulsive applications to the abdomen, more especially to the 
epigastrium and right hypochondriac region, should be used. So far 
as my own experience enables me to judge, blistering the region of 
the stomach is decidedly the most efficient application of this kind in 
the present affection. Before the blister is applied, the part should 
be slightly bathed with spirits of turpentine, in order to procure 
vesication as speedily as possible. I have seldom, however, suffered 
the vesicatory to remain on the skin longer than four hours. As 
soon as the skin is uniformly inflamed, which in children occurs 



30S CHOLERA. 

generally in about four hours, and sometimes much sooner, the can- 
tharides should be removed, and an emollient poultice applied over 
the whole abdomen, including of course the inflamed surface. This 
will, in a short time, excite the inflamed vessels to pour out a copious 
quantity of serum under the cuticle, and form a large blister, which 
should then be opened and dressed with fresh mercurial ointment, 
prepared without turpentine or other irritating substances. Where 
the general habit is phlogistic, and the pulse manifestly febrile, leech- 
ing both from the head and the region of the liver are important pre- 
liminaries to the employment of vesicatories. 

The warm bath, also, is an excellent auxiliary in the treatment of 
this disease; and this measure is especially indicated, when the skin 
is very dry and harsh, and the pulse quick and tense. While the 
patient is immersed in warm water up to the neck, it will be proper 
to apply a napkin wet with cold water to the head.' Various other 
external applications to the abdomen have been recommended, for 
the purpose of moderating the gastro-intestinal irritability in this 
affection. Rubefacient embrocations and cataplasms, made of stimu- 
lating herbs and spices, may be beneficially applied to the abdomen; 
and where the disease is violent and rapid in its progress, recourse 
should be had to the most active articles of this kind — such as sina- 
pisms, ol. monardse,* spirits of turpentine, and even diluted nitric 
acid, in the way mentioned for the treatment of the cholera of adults. 

I have already stated, as a general rule, that the use of opium is 
highly improper in this affection. The great tendency to congestion 
and irritation of the brain, in this species of cholera, renders all 
medicines of this kind decidedly prejudicial, when given in the early 
period of the disease, or where, in its advanced stage, symptoms of 
cerebral oppression are manifestly present. Nevertheless, where the 
disease assumes a chronic form, and the patient is very restless and 
wakeful, with a dry, harsh, and withered state of the skin, and there 
are no particular marks of cerebral congestion, small doses of Dover's 
powder, in union with minute portions of calomel, will sometimes 
produce very excellent effects. In a few instances of this kind, I have 
given half a grain of Dover's powder, with the sixth of a grain of 
calomel, and two grains of magnesia, every two hours, to a child 
under two years old, with unequivocal advantage. I must confess, 
however, that I have witnessed some instances of this kind, in which 
the employment of this narcotic was speedily followed by more or 
less stupor and cerebral oppression, without any beneficial effect on 
the intestinal disorder. 

With regard to the astringent and absorbent remedies, formerly 
so much employed in this affection, we can scarcely pronounce too 
strong a sentence of condemnation against their use in the acute 
form or stage of this malady. I am entirely persuaded, that "much 
of the mortality of the disease has been produced" by the injudi- 
cious employment of cretaceous juleps, astringent mixtures, aromatic 

* K. — 01. monardae, %i. 

Spirit camphors:, ^ss. 



CHOLERA. 309 

draughts, and opiates. Where the disease becomes chronic, or con- 
tinues rather in the form of chronic diarrhoea than of cholera, the 
milder astringents may occasionally do some good. Thus, I have, 
in a few cases, known a decoction of the root of the geranium macu- 
latum in milk, procure considerable advantage; but I have much 
more frequently found it either to produce no manifest impression on 
the disease a't all, or to do injury. The employment of unirritating 
tonics, in the chronic form of the disease, attended with great debility 
and relaxation, is much more apt to afford relief, than the use of 
astringents and absorbents. I have frequently procured considerable 
benefit, in the advanced periods of the disease, from the employment 
of a solution of the tartrate of iron. Forty grains of this preparation 
may be dissolved in two ounces of water, to which half an ounce 
of the lemon syrup is to be added. Of this, from thirty to forty drops 
may be given to an infant, four or five times daily. Dr. Robert 
Jackson speaks very highly of finely powdered charcoal in diseases 
of the intestinal canal attended with diseased secretions; and Dr. 
Condie states, that he has used this article with very decided advan- 
tage, "in the latter stage of the disease, when it had become in some 
degree chronic, and the discharges from the boweis were acrid, dark- 
coloured and offensive." From my own experience, I can say no- 
thing of this remedy, but I do not doubt its occasional usefulness 
under the circumstances just mentioned. From five to ten grains of 
the powdered charcoal, with four or five grains of rhubarb and a 
grain of ipecacuanha, may be given every three hours. (Condie.) 

When, from the violence and rapidity of the disease, or its long 
continuance, the exhaustion becomes very great, the extremities cold, 
and the pulse very small and feeble, internal, as well as external 
stimulants, become necessary. Under such circumstances, stimulating 
frictions, together with the internal use of wine-whey, milk-punch, 
or a weak solution of the carbonate of ammonia, are indispensable 
to support the sinking energies of the system. 

To relieve the colic pains which are apt to occur from flatulent 
distension of the bowels in the advanced periods of chronic cholera 
infantum, Dr. Condie strongly recommends a few drops of the spirits 
of turpentine ; and my own experience enables me to speak favour- 
ably of this remedy. I have, generally, however, preferred the oil 
of juniper to the turpentine, and I am inclined to think it more cer- 
tain in its effects in this respect, than the latter. No remedy has 
appeared to me so promptly to allay colic pain, and promote the 
expulsion of flatus from the bowels, as a weak solution of common 
soot sweetened with sugar. 

Particular attention must be paid to the proper regulation of the 
diet, throughout the whole course of the disease. If the child is 
weaned, nothing but the blandest liquid articles of food must be 
allowed. Boiled milk; liquid preparations of arrow-root, tapioca, 
sago, and rice ; thin oatmeal gruel, barley decoction, or a solution 
of gum arabic, are the best articles for food and drink in every stage 
of cholera. In some instances, of a chronic character, I have known 
beef-tea, or weak chicken broth, to produce a favourable change in 



310 COLIC. 

the state of the stomach and bowels. In chronic cholera infantum, 
the appetite sometimes suddenly begins to crave urgently for certain 
strong and stimulating articles of food, such as salted herring or shad ; 
old bacon ; salted and smoked beef, &c, whilst the stomach loathes 
all the lighter and unirritating articles of nourishment enumerated 
above. When this occurs, it will be proper cautiously tp gratify the 
newly awakened appetite, however opposed to the ordinary dietetic 
rules the indulgence may appear to be. " I have seen many children 
recover," says Dr. Rush, "from being gratified in an inclination to 
eat salted fish, and the different kinds of salted meat. In some in- 
stances they evince an appetite for butter, and the richest gravies 
of roasted meat, and eat them with obvious relief to all their symp- 
toms." Without these strong instinctive calls of nature, however, 
it would be highly improper to allow such coarse articles of food ; 
yet where the inclination for them is strongly expressed, it may, and 
ought to be gratified. 

Nothing contributes more to the removal of this disease, than the 
enjoyment of the pure air of the country. Whenever it is practica- 
ble, the little patient ought to be removed into the country; for this 
change is often sufficient to remove the disease, in a short time, with- 
out any other remedial applications. If the circumstances do not 
admit of a removal from home to a suitable situation in the country, 
some advantage may be gained, by carrying the patient about in the 
open air; and still more, by frequent rides into the country in an open 
carriage. 

As preventive measures, gestation, or residence in the pure air of 
the country; the avoidance of cool night air after a very warm day; 
nourishment at the breast during the process of dentition, or where 
circumstances render this impracticable, a very light liquid diet — 
particularly milk, and a thin preparation of arrow-root, with beef-tea, 
or weak chicken broth, tepid bathing, and lancing the gums as soon 
as they become swollen by the protruding tooth, are the most im- 
portant.* 



Sect. IV. — Colic. 

Writers have divided colic into a great many varieties ; but as 
most of these distinctions are mere nosological refinements, I shall 
notice those only which have a practical bearing. 

The most common variety of colic is that which is occasioned by 
irritating and indigestible articles of food, and which Dr. Gregory, 
from this circumstance, calls accidental colic; but which is more 
commonly designated by the term flatulent, from the prominent 
symptoms of indigestion and flatulency which always attend this 
painful affection. 

* [Daily scarifications of the gums in a still earlier stage of dentition after the 
manner prescribed by Dr. Marshall Hall, has become a popular method in this 
city. — Ma] 



COLIC. 311 



1. Flatulent Colic. 



A weak and irritable state of the digestive organs, predisposes, 
in an especial manner, to this variety of colic. In persons so predis- 
posed even the ordinary articles of food will sometimes give rise to 
the disease ; and when food of an indigestible character is taken 
more or less suffering from colic is almost inevitable. Salted meats 

all kinds of pastry —crude vegetables, such as cucumbers, celery, 

and unripe fruit — sour fruit — fresh and warm bread, &c, are espe- 
cially apt to excite the disease in persons labouring under weak 
digestive powers. When articles of this kind are received into the 
stomach no inconvenience is usually felt until an hour or two after 
they are swallowed. In some instances, where the stomach is weak 
and irritable, the food passes into the bowels in an imperfectly 
digested state ; in which case, the colic pains may not come on for 
several hours after eating, and usually occur most severely about the 
umbilical region. More commonly, however, the pain commences 
in the stomach or duodenum, before the offending substances have 
had time to pass lower down in the alimentary canal. At first, 
the patient experiences a sense of distension and uneasiness in the 
pit of the stomach, or occasionally in the left iliac region. This is 
soon followed by a dull, peculiarly distressing, and sickening pain in 
these parts, accompanied with a feeling of strong distension of the 
stomach and bowels. The pain now rapidly increases in violence, 
until it becomes extremely severe. In some cases, the pains continue, 
with but short remissions, for several hours. More commonly, 
however, they occur in severe paroxysms, with complete, though 
transient intervals of ease. During the exacerbations, the patient is 
apt to move to and fro, with the body bent forwards, and the hands 
firmly pressed against the abdomen. When the stomach is the prin- 
cipal suffering organ, large quantities of air are, from time to time, 
forced up, and this is generally immediately followed by some miti- 
gation of the pain. When the colon is the part chiefly affected, the 
flatus sometimes passes off downwards ; but this seldom takes place 
to any considerable extent, until the disease is about terminating. 
The bowels are always torpid in this affection, and the tongue soon 
becomes covered with white fur. 

Diagnosis. — The diagnosis of this variety of colic is not attended 
with any difficulty. The relief obtained from firm abdominal pres- 
sure— the agitation and writhing motion of the patient; as well as 
the absence of fever, and the paroxysmal character of the pains, and 
frequent eructations of flatus, distinguish it prominently from gastro- 
intestinal inflammation. From bilious colic it may be distinguished 
by the absence of bilious "vomiting, as well as of the icterode appear- 
ance of the eyes, of the extreme obstinacy of the constipation, and 
of the headache and bitter taste in the mouth, which characterize 
the bilious variety of colic. From colica pictonnm it is readily dis- 
tinguished by the hardness and retraction of the abdominal muscles, 
and the gradual accession of the colic produced by lead. 

Prognosis. — Flatulent colic is not attended with much danger, 



312 colic. 

unless it terminates in inflammation of the gastro-intestinal mucous 
membrane — a termination which sometimes though rarely occurs. 
In some instances where the flatulent distension is very great, it 
produces paralysis of a portion of the bowels, or destroys to a de- 
gree, the power of contraction, giving rise to habitual costiveness, 
and an especial tendency to a recurrence of the complaint. It is not 
improbable, that paralysis of a portion of the intestinal canal, in- 
duced in this manner, may be the principal occasion, in some cases 
of introsusception, or invagination of the bowels. Where flatulent 
colic is produced by very indigestible and irritating ingesta, it may 
give rise to rapid inflammation and gangrene. 

Treatment. — The treatment of this variety of colic is seldom at- 
tended with much difficulty. In slight cases, where the flatulent 
pains are seated in the stomach, and there is no reason to presume 
the existence of chronic irritation in the mucous membrane of this 
organ, we may, in general, soon procure relief by administering 
some of the carminative and antispasmodic stimulants. Dry frictions 
with flannels or a flesh-brush, is an excellent means for removing 
flatulent pains of the stomach. By rapid frictions on the epigas- 
trium, the flatus is generally discharged in copious torrents, and 
where there is no fixed irritating cause in the stomach that requires 
removal, we may often, in this way, put a termination to the gastric 
pains. From five to ten grains of camphor with about thirty drops 
of vitriolic ether, and the same quantity of laudanum, has frequently 
afforded prompt relief in my hands. The oil of juniper or the spirits 
of turpentine will also generally allay the pain in slight cases. Ar- 
ticles of this kind will, in general, give relief where there is no par- 
ticular irritating cause lodged within the alimentary canal ; but 
where the disease is the consequence of crude indigestible and irri- 
tating ingesta — or where it comes on within an hour or two after 
taking a full meal of stimulating mixed, and indigestible food, car- 
minatives and antispasmodics will not only be insufficient, but gene- 
rally decidedly injurious, unless they are used in conjunction with 
proper evacuants. Where there is reason to believe that the offend- 
ing matter is still in the stomach — which may be presumed to be the 
case when the disease comes on within an hour or two after taking 
a full meal, recourse should at once be had to an emetic dose of ipe- 
cacuanha. To moderate the excessive suffering of the patient as 
speedily as possible, we may administer some carminative along 
with the emetic. From twenty to twenty-five drops of the essence 
of peppermint, may be advantageously given in such cases, with 
about thirty grains of ipecacuanha. When the pain is confined to 
the bowels, occupying the colon, an active purgative in union with 
aromatics, or with some of the more volatile antispasmodics, ought 
to be given and purgative enemata administered at short intervals 
until the bowels are freely moved. Castor oil with spirits of turpen- 
tine is an excellent purgative in colic from the irritation of acrid sub- 
stances or imperfectly digested articles of food lodged in the bowels. 
I have often employed this mixture with prompt and complete 
success. In some instances, however, the sufferings of the patient 



colic. 313 

are so extremely great, that we cannot wait for the operation of a 
cathartic to procure relief. In such cases, almost the only remedy 
upon which any reliance can be placed is opium, given in large 
doses. From two to three grains should be given at once, or what is 
better an equivalent dose of laudanum. This will always procure 
relief in the course of forty or fifty minutes; and in many instances 
of this severe character, nothing but this remedy, in enormous doses, 
will allay the extreme agony of the patient. The opium, when 
given in large doses in this affection, does not materially impede the 
subsequent operation of cathartics— and . the administration of a 
purgative should never be neglected as soon as the violence of the 
disease is moderated.* When the disease occurs in robust and ple- 
thoric habits, venesection should be practised, in order to obviate the 
occurrence of inflammation, and to promote the operation of the 
necessary purgatives. Little or no advantage usually results from 
the employment of external revulsive applications ; yet when, after 
the subsidence of the colic pains, the epigastrium remains tender to 
pressure, and the tongue becomes furred in the middle, with a florid 
appearance of the edges, leeching and blistering cannot be safely 
dispensed with. 

After the disease has been subdued, the patient should confine 
himself to the lightest and most digestible articles of food for several 
days. 

2. Bilious Colic. 

There is another variety of colic, which, from the manifest de- 
rangement of the biliary organs, and symptoms indicative of a 
superabundant or vitiated secretion of bile, has with propriety been 
denominated bilious cholic. 

This variety of the disease appears to depend on the same remote 
cause which gives rise to intermitting, remitting, and other forms of 
miasmatic fevers : and it accordingly most commonly occurs during 
the autumnal months — particularly after a long continuance of a 
very warm and humid state of the atmosphere. 

Before the more urgent and characteristic symptoms of the disease 
come on, the patient generally experiences headache, loss of appetite, 
a bitter taste in the mouth, thirst, nausea, and occasionally bilious 
vomiting. After these symptoms have continued for an indefinite 
period of time, acute pain in the stomach and bowels supervenes, 

* For this purpose, we may use either castor oil and turpentine, in the pro- 
portion of six drachms of the former to two drachms of the latter — or the follow- 
ing pills : 
H. — Extract, colocynth. compos., gss. 
Calomel 9i. 

Tart, aiitimonii gr. i. — M. Divide into ten pills. Take two every hour 
until the bowels are freely moved. — Or, 
fi. — Pulv. jalapa gr. xvi. 

Calomel "r. viii. — M. To be taken, all at once. 



314 colic. 

moving at first from one part of the abdomen to another, though 
generally most severely felt about the umbilicus. This pain is often 
intensely severe during the exacerbations. In the early stages of 
the complaint, pressure on the bowels affords some degree of relief; 
but as the disease advances, the abdomen becomes tender to the 
touch. Nausea and bilious vomiting occur more or less frequently 
from the commencement of the malady ; and the patient always ex- 
periences a temporary abatement of his sufferings immediately after 
a spell of vomiting. Although the stomach is morbidly irritable, 
and extremely apt to be excited to vomiting, yet the bowels are 
almost invariably extremely torpid, being generally in a state of 
obstinate constipation from the beginning of the disease. The pulse 
seldom deviates materially from its natural condition during the 
early period of the complaint ; but in the advanced stage it becomes 
increased in fulness, force and frequency. In violent cases, the 
hands and feet are sometimes quite cold during the exacerbations of 
the pains. About the second or third day of the disease, the eyes 
and skin become more or less suffused with a yellow tinge ; and in 
some cases, indeed, these manifestations of biliary disorder occur 
several days before the pain in the abdomen commences. 

In cases of great severity, the nervous system usually suffers con- 
siderable disturbance — the patient becoming despondent and affect- 
ed with slight spasmodic twitches in the muscles of the extremities.* 
Dr. Staley, in the interesting paper on this disease just referred to, 
observes, that he has sometimes met with cases in which much numb- 
ness and tremor of the superior extremities occurred ; and he saw one 
case in which the " arms were so completely paralyzed that all power 
of voluntary motion was destroyed." Paralysis of the wrists has, 
indeed, been frequently noticed as an occurrence in this affection, and 
this circumstance has been adduced as an argument in favour of the 
identity of this affection with the variety of colic produced by lead. 
Eructations of flatus are very common in bilious colic ; and, as in the 
former variety of the disease, they are always followed by a tempo- 
rary mitigation of the abdominal pain. 

Causes. — I have already said that bilious colic appears to depend 
on the same remote cause which gives rise to autumnal bilious fever. 
Dr. Rush includes this variety of colic among the usual forms of 
miasmatic fevers;. and Dr. Staley observes, that he has uniformly 
found "the cases of bilious colic most numerous after a summer re- 
markable for the prevalence of bilious remitting and intermitting 
fever." My own observations correspond fully with these state- 
ments. In the autumn of 1821, 2, and 3, when bilious remittents 
prevailed very extensively, I met with a greater number of cases of 
bilious colic than had previously come under my notice during a 
period of fifteen years. Although there can scarcely exist a reason- 
able doubt that koino-miasmata is intimately concerned in the pro- 
duction of this malady— more especially when it prevails, in a degree 

* An Inquiry relative to the Causes, Nature, and Treatment of Bilious Colic 
By Dr. Henry Staley, of Maryland.— See Medical Recorder, vol. vi, p. 231. 



colic. 315 

epidemically; it must nevertheless be admitted, that other causes, of 
a sporadic character, occasionally give rise to this affection. I have 
met with cases of strongly-marked bilious colic under circumstances 
that precluded all ideas of the agency of miasmata. 

It is generally believed that the liver is morbidly active in this 
disease — and that a redundant secretion of bile is one of its most 
essential conditions. This idea is favourd by the circumstance, that 
from the very commencement the fluid thrown from the stomach 
is always mixed with a considerable portion of bilious matter. There 
is much reason, however, to doubt the correctness of this opinion. 
Dr. Staley observes, with much plausibility, that if we reflect on the 
quantity of bile which is secreted in a healthy individual, and the 
obstruction which exists to its passage downwards, from the constipa- 
ted state of the bowels in this disease, we can have no difficulty in ac- 
counting for the quantity of bile discharged by the mouth, although 
there be a paucity in the secretion. It is not improbable, indeed, 
that so far from there being too copious a secretion of bile in this 
disease, there is, in fact, generally, a deficiency of this fluid. The 
functions of the liver are unquestionably deranged, and the bile se- 
creted is, without doubt, vitiated. That this is the case, may be 
inferred from the analogy which bilious colic bears to cholera — an 
analogy which has been particularly noticed by many writers. Dr. 
Gregory observes, "that bilious colic is closely allied to bilious diar- 
rhoea and cholera, occurring along with them, and apparently differing 
from them only in some unessential features." The opinion that 
the liver is in a state of torpor rather than of increased activity, is 
moreover strengthened by the fact, that so soon as the alvine dis- 
charges become bilious, an amendment of the disease usually takes 
place; and that however frequent the discharges may be, they seldom 
procure any particular relief when they are devoid of bilious matter. 
"When bilious stools are not brought away," says Dr. Gregory, "it 
is common to find chocolate coloured motions passed, frequently in 
vast quantity, reducing the patient to a state of great weakness." Dr. 
Musgrave, in a valuable paper on this disease, states that he inva- 
riably found the liver in a highly congested state, and in the majority 
of instances there were strong marks of intestinal inflammation and 
its consequences.* 

The etiology of bilious colic does not appear to differ materially 
from that which is common to cholera, dysentery, &c. The atmo- 
spheric heat and miasmata act probably as predisposing causes; and 
sudden changes of atmospheric temperature, by which the cutane- 
ous exhalents and secretory vessels of the liver are struck torpid, 
and the blood determined to the internal organs, constitute perhaps 
the principal exciting cause of the disease. j 

Treatment. — The principal indications in the treatment of bilious 
colic are : to free the bowels of their irritating contents; to allay the 
morbid irritability of the stomach and intestinal tube, and to restore 
the healthy actions of the liver. Some writers speak very favour- 

* Med. Repository. Nov. 1825. 



316 colic. 

ably of the employment of emetics in the beginning of the disease, 
and there can be no doubt of their usefulness where there is much 
nausea, without full vomiting in the commencement of the attack. 
Under such circumstances, the exhibition of an emetic, should be 
among the first measures resorted to for the removal of the disease. 
Much bilious matter, of a vitiated appearance, is usually thrown off, 
and considerable temporary relief, almost invariably, ensues. In 
cases attended with much spontaneous vomiting, it will not be ne- 
cessary to resort to the use of emetics. In such instances, it will be 
sufficient to request the patient to take copious draughts of eupato- 
rium or chamomile tea, or some other diluent, in order to facilitate 
the complete evacuation of the vitiated bile and other irritating 
matters lodged in the stomach. Where an emetic is indicated, the 
tartarized antimony will in general answer better than any other 
article of this kind, on account of its greater tendency to excite the 
action of the liver and of the alimentary canal. Many writers ad- 
vise the exhibition of purgatives, as soon as the stomach has been 
well freed of its irritating contents. But in the majority of cases, the 
stomach is so extremely irritable, that medicines of this kind cannot 
be retained a sufficient length of time to enable them to act on the 
bowels. As the early evacuation of the intestinal canal, however, 
is all-important, measures should be immediately taken to allay the 
gastric irritability, so as to enable us to administer a cathartic with 
a prospect of advantage as early as possible. So far as my own ex- 
perience enables me to decide, calomel is decidedly the best internal 
remedy we possess, for preparing the stomach for the reception and 
retention of purgatives. Given in small and frequent doses, in con- 
junction with the application of sinapisms or epispastics to the epi- 
gastrium, this mercurial will seldom disappoint us in allaying the 
irritability of the stomach, sufficiently to enable us to administer 
with effect the necessary cathartics. What renders this remedy still 
more useful as an antecedent measure to the use of purgatives, is its 
well known powers to correct functional disorder of the liver, as 
well as its tendency to co-operate as an aperient with the purgatives 
which are to follow. After the stomach has been freed of its contents, 
either by spontaneous vomiting, or the operation of an emetic, half 
a grain of calomel may be given every half hour, at the same time 
that a large epispastic is applied to the region of the stomach and 
liver, and continued until the gastric irritability is moderated. When 
this is accomplished, a full dose of some active purgative should be 
administered; and for this purpose we may give from fifteen to twenty 
grains of calomel, followed in about three hours with an ounce and 
a half of castor oil, or a draught of strong infusion of senna and manna. 
In some instances, however, none of the usual purgatives will be 
retained, notwithstanding the previous employment of small doses 
of calomel and counter-irritating applications to the epigastrium. 
Where this is the case, it is best to depend on calomel alone, with 
the view of procuring the evacuation of the bowels. "When the 
gastric irritability is very great, calomel," says Dr. Staley, "com- 
bined with gum arabic, will be retained, when every other cathartic 



colic. 317 

will be rejected." This corresponds entirely with my own experi- 
ence. I have, in several instances, ultimately procured free alvine 
evacuations by administering from five to six grains of this mercu- 
rial every three or four hours, until from twenty to thirty grains are 
taken, and then assisted by repeated purgative enemata. The em- 
ployment of enemata should, indeed, always accompany the use of 
purgatives in this affection. An excellent injection for this purpose, 
is the following mixture of castor oil and turpentine;* or we may 
use a strong infusion of senna and Glauber salts. As soon as the 
bowels are freely evacuated, a full dose of opium ought to be admin- 
istered. This valuable narcotic allays the irritation and spasmodic 
contraction of the intestines ; and when given in combination with 
calomel, it does not impede the subsequent operation of cathartics, 
and tends, in no small degree, to equalize the circulation, and to ex- 
cite the cutaneous and hepatic functions. When the obstinacy of 
the disease is very great, and the bowels resist the effects of purga- 
tives, the calomel, with an occasional dose of opium, should be given 
with a view to its constitutional influence. In general, cathartics will 
operate freely as soon as the mercurial influence is manifested by the 
soreness of the gums. A general mercurial action has, in fact, a most 
beneficial influence upon the disease, whatever may be its grade of 
violence; and in prescribing calomel in the commencement of the 
disease, with a view of its purgative effects, we must not lose sight 
of the more permanent and equally important influence, procured by 
its specific effects upon the system, and particularly upon the liver. 
Deranged hepatic function constitutes, probably, the foundation of 
the malady ; and the removal of this morbid condition should be held 
a primary object in the treatment. After the bowels have once been 
freely evacuated, we must by all means endeavour to keep up regu- 
lar alvine evacuations throughout the subsequent course of the disease. 
For this purpose, castor oil, or infusion of senna and manna, with 
an occasional dose of calomel, and the daily use of one or two pur- 
gative enemata, will in general answer very well. 

In robust and plethoric subjects, or where the pulse is vigorous and 
tense, and the tenderness to abdominal pressure considerable, blood- 
letiing is a very important auxiliary remedy in this affection. It not 
only tends to moderate the irritability of the stomach, and to favour 
the regular operation of the necessary purgatives, but what is still 
more important, it lessens the liability to inflammation, which, in ple- 
thoric and robust habits, is always very considerable in this affection. 
When the pulse is vigorous, it will be best, at once, in the commence- 
ment of the disease, to draw the blood to the extent of making a 
decisive impression on the system ; and the operation may be. advan- 
tageously repeated whenever the state of the pulse, and other symp- 
toms, indicate its propriety, at every stage of the disease. 

* R. — 01. ricini giss. 

Spir. terebinth. f ss. 
Infus. sem. lini. Oj. 
Sapo venet. 31. — M 



318 colic. 

Epispastics, sinapisms, and warm fomentations, also, are valuable 
auxiliaries to the remedies already mentioned. When the irritability 
of the stomach is very great, or when the epigastrium and abdomen 
are very tender to the touch, a large epispastic should be applied over 
the region of the stomach — having previously practised an efficient 
blood-letting — and an emollient cataplasm laid over the lower part of 
the abdomen. These applications assist, in no inconsiderable degree 
to allay the irritability of the stomach ; and they are especially useful, 
also, to obviate intestinal inflammation — an occurrence which it must 
always be our principal aim to prevent. 

When, in the beginning, the fluid thrown from the stomach is of 
an acrid quality, alkaline remedies should be administered. Calcined 
magnesia may be given either in union or in alternation with other 
purgative medicines; or from twenty to thirty grains of the bicarbo- 
nate of potash, dissolved in a draught of senna and manna. 

The warm bath occasionally affords considerable relief in violent 
cases of this affection : and warm fomentations to the abdomen may 
be very beneficially used. 

After the disease has been subdued, much care is necessary on the 
part of the patient, in relation both to diet and exposure. There are 
few diseases which are so apt to be re-excited by even slight errors 
in either of these respects, as the present one. For eight or ten days 
after an attack of this disease, the diet should be of the lightest and 
most digestible kind. Rice, sago, dry toast, beef tea, &c, should be 
used for three or four days, after which small quantities of the most 
digestible meats may be allowed. It is particularly important to 
avoid getting cold and damp feet. To lessen the liability to a relapse, 
it will be proper to wear a flannel roller round the abdomen for some 
time after the subsidence of the disease; and the patient must be par- 
ticularly cautioned against drinking very cold water, during the first 
three or four days of convalescence. 

3. Colica Pictonum. 

This variety of colic has been described under a diversity of names 
— as dry gripes; Devonshire colic ; colica pictavensis; c. saturnina; 
c. damnoniensis ; rachialgia metallica ; painter's colic, &c. It gene- 
rally makes its approaches in a very gradual maimer — commencing 
with symptoms of gastric derangement, such as irregular and weak 
appetite, foul eructations, languor, slight nausea, constipation, with 
transient pains, and a feeling of weight and tightness in the abdomen, 
more or less drowsiness, and disinclination to mental and corporeal 
exertion. By degrees, the pain in the epigastrium and umbilical 
region becomes more and more severe and constant. The abdomen 
is hard, retracted, and somewhat tender to pressure, the bowels im- 
movably torpid, and the stomach, in most instances, very irritable. 
The pain in the abdomen suffers occasional remissions, but except 
for a moment after vomiting, and in mild cases, no perfect intermis- 
sions take place, as in the other varieties of colic. The exacerbations 
of the colic pains are protracted in duration, and exceedingly agoniz- 



colic. 319 

ing; and during the first two or three days, the retching and vomiting 
is generally very distressing, although a momentary mitigation is 
usually experienced, immediately after the contents of the stomach 
are ejected. In violent and rapid cases, or what may be called the 
acute form of the disease, the pains extend from the umbilical region 
upwards to the chest and arms, and downwards to the pelvic viscera, 
giving rise to paroxysms of violent pain in the region of the bladder 
and rectum, with much difficulty of voiding urine, and a distressing 
sense of weight, constriction, and bearing down in the lower part of 
the abdomen. During the exacerbations, the anxiety and agitation 
are extreme — cold sweats break out on the extremities and face; the 
countenance is pale, contracted, and expressive of great suffering ; and 
in some cases of very great violence, partial syncope, delirium, con- 
vulsions, paralysis of the wrists, and severe pains in the extremities 
occur. When remedial measures fail to make a favourable impres- 
sion on the disease, the vital energies at last begin to sink ; the ab- 
dominal pains abate ; the stomach becomes extremely tender and 
puffy ; the thirst unquenchable ; vision imperfect ; and finally, oedema 
of the feet, drowsiness, a pale, livid hue of the face, and occasionally 
suppression of urine, and more or less tenesmus, with great dyspnoea 
ensue ; and the patient dies under symptoms of apoplexy, or in a 
state of syncopic insensibility. 

Colica pictonum, if not subdued by an appropriate treatment, or if 
the remote cause continues to act on the system, or the patient has 
already suffered one or two attacks of the disease, is particularly apt 
to assume a chronic character, and to become associated with a variety 
of fixed and peculiarly distressing affections. The excretory and nu- 
tritive functions become impaired ; the mental and physical energies 
torpid ; the capillary circulation extremely inactive, giving rise to a 
pale, sallow, and leaden hue, and a shriveled, dry, and harsh state of 
the surface of the body; the temper becomes irritable, desponding, 
taciturn, and gloomy ; the countenance lurid, and expressive of deep 
suffering ; the body emaciates ; the forearms become wasted and 
palsied; the abdomen exceedingly hard, painful to pressure, and 
tumid ; the legs cedematous, with pains in the joints, particularly in 
the ankles and toes, and great tenderness of the soles of the feet. The 
patient is extremely restless at night, his vision becomes weaker and 
weaker, the oedema extends up the legs, and the abdomen enlarges 
with dropsical accumulations. In some cases, paraplegia, epilepsy, 
mania, or total imbecility of mind ensue ; and the patient is at last 
reduced to a state of complete exhaustion and emaciation, and dies 
under symptoms of apoplexy, or of dropsical effusion into the cavity 
of the thorax, pericardium, &c. 

On post-mortem examination, traces of inflammation, with 
patches of disorganization, almost always occur in the mucous mem- 
brane of the stomach and intestinal canal. Frequently, portions of 
the intestines are so contracted as scarcely to admit the passage of an 
ordinary sized quill ; and occasionally the stomach, and whole track 
of the bowels, are in a state of preternatural contraction. The vessels 
of the abdominal and thoracic viscera are generally very turgid with 



320 COLIC. 

blood ; but the muscular structure, everywhere, exhibits a pale and 
exsanguinous appearance. The omentum is often marked with livid 
spots. M. Thomes, a late French writer, states that in the dissection 
of eleven persons who had died of this disease, he found the meninges 
of the brain strongly injected, together with softening and other mor- 
bid appearances of the cerebral structure, with serous or sanguineous 
extravasations between the membranes. 

Causes and nature. — Lead, in whatever way and form it maybe 
brought to act on the system, is almost the only well-ascertained cause 
of this variety of colic. It would seem that the fumes of melted lead 
and the white oxide of this metal, are most apt to act injuriously on 
the animal system, and to give rise to this extremely distressing affec- 
tion. It has been said, that the acetate of lead is incapable of producing 
this disease, and that no apprehensions need be entertained on this 
account, in prescribing the internal use of this article. It must be 
admitted, indeed, that the acetates manifest a much less deleterious 
tendency in this way, than anyof the other forms under which this 
metal may exert its poisonous influence on the system. It would 
appear that the tendency of lead to produce colic is not confined to 
the human species. It has been distinctly noticed, that in the neigh- 
bourhood of smelting furnaces and white lead manufactories, pigs, 
poultry, and other animals, occasionally become affected with a similar 
disease. Plumbers, painters, glaziers, gilders, the workers in lead 
mines, and in white lead manufactories, are most exposed to the in- 
fluence of this poison, and of course almost peculiarly liable to this 
disease. Formerly it was the practice, in some parts of Europe, to 
put litharge into new made wine, for the purpose of rendering it 
palatable, or to convert acid into sweet wine. This gave rise to the 
extensive prevalence of this form of colic in some districts ; and it is 
from its endemic prevalance at Poitou in France, from this cause, 
that the disease obtained the name of colica pictonum* 

It has been contended, nevertheless, that other causes are capable 
of producing this variety of colic. Crude wine, fresh cider, and 
other drinks, acidulated with fresh vegetable juices, are mentioned 
as possessing a tendency, under otherwise favourable circumstances, 
to produce this disease ; but the correctness of this opinion has, I 
think, with great propriety been doubted ; for if the circumstances 
attending the occurrence of instances of this kind are accurately in- 
vestigated, it will, perhaps, generally be found, that in such cases 
these drinks had been tainted with lead employed in some part of the 
machinery or vessels made use of. Without doubt, such beverages 
may give rise to severe colic ; but we have no satisfactory evidence 
that they are capable of producing the protracted train of distressing 
symptoms which are known to arise from the poisonous influence of 

* [A new pathognomonic sign has of late been much insisted on by foreign 
physicians, i. e. a lividity or blueness of the gums, or rather of that portion of the 
gums which is immediately adjacent to the teeth. If lead has been in any way 
introduced into the system it is supposed that it must always discolour the gums in 
this way. — Mc] 



colic. 321 

lead. Larrey, and some other late writers assert, that atmospheric 
vicissitudes, in conjunction with malaria, are a frequent source of 
this form of colic ; but it is probable, that when produced by these 
causes, the disease does not differ from the preceding variety — name- 
ly, bilioiis colic. It has indeed been maintained, that the affections 
called bilious and lead colic, are essentially the same ; but, although 
the former often bears a very close resemblance, in its course and 
phenomena, to the latter, the more decided manifestations of biliary 
derangement in the former, and the great aptitude of the latter to 
pass into a chronic state, and to become complicated with various 
affections of a most distressing character, among other distinctive cir- 
cumstances, seem to indicate a radical distinction between them. Of 
the nature or proximate cause of colica pictonum, there is but little 
known of a satisfactory character. That the nervous system is promi- 
nently affected, is very evident ; but whether the ganglionic or the 
cerebral nerves are the seat of the primary irritation, is by no means 
evident. M. Thomas, to whose dissections I have already referred, 
conceives that the primary location of this affection is in the brain: 
but the facts upon which he grounds this opinion— namely, the very 
obvious traces of high vascular congestion, and other organic affec- 
tions of the brain which are frequently detected on po